Parent/Caregiver Contact Name *

First Name

Last Name

I am Interested in the below dates for PLAAY on the Move *

February 23 at the National History Museum

April 25 at Cleveland State University

My child moves around by: *

(please answer regarding Child #1)

Being held or carried by a parent or caregiver

Rolling or scooting on the floor

Crawling or creeping

Walking or cruising along furniture

Running, jumping, climbing

Being pushed in a stroller or wheelchair

Other (please provide comment)

My child is most comfortable when *

(please check all that apply for Child #1)

Noises are kept to a minimum

Lights are dimmed

In open spaces

Playing with other children

Playing with adults

Activities have a lot of visual interest

They have free play

They have structured play

None of the above

Other

My child plays with toys by *

(please check any and all that apply for Child #1)

Looking at them

Having help from an adult

With his/her hands

Playing themselves

Playing with friends

Using toys creatively

Other

My child moves around by:

(please answer regarding Child #2)

Being held or carried by a parent or caregiver

Rolling or scooting on the floor

Crawling or creeping

Walking or cruising along furniture

Running, jumping, climbing

Being pushed in a stroller or wheelchair

Other (please provide comment)

My child is most comfortable when

(please check all that apply for Child #2)

Noises are kept to a minimum

Lights are dimmed

In open spaces

Playing with other children

Playing with adults

Activities have a lot of visual interest

They have free play

They have structured play

None of the above

Other

My child plays with toys by

(please check any and all that apply for Child #1)

Looking at them

Having help from an adult

With his/her hands

Playing themselves

Playing with friends

Using toys creatively

Other

My child moves around by:

(please answer regarding child #3)

Being held or carried by a parent or caregiver

Rolling or scooting on the floor

Crawling or creeping

Walking or cruising along furniture

Running, jumping, climbing

Being pushed in a stroller or wheelchair

Other (please provide comment)

My child is most comfortable when

(please check all that apply for Child #3)

Noises are kept to a minimum

Lights are dimmed

In open spaces

Playing with other children

Playing with adults

Activities have a lot of visual interest

They have free play

They have structured play

None of the above

Other

My child plays with toys by

(please check any and all that apply for Child #3)

Looking at them

Having help from an adult

With his/her hands

Playing themselves

Playing with friends

Using toys creatively

Other

My child moves around by:

(please answer regarding child #4)

Being held or carried by a parent or caregiver

Rolling or scooting on the floor

Crawling or creeping

Walking or cruising along furniture

Running, Jumping, climbing

Being pushed in a stroller or wheelchair

Other (please provide comment)

My child is most comfortable when

(please check all that apply for Child #4)

Noises are kept to a minimum

Lights are dimmed

In open spaces

Playing with other children

Playing with adults

Activities have a lot of visual interest

They have free play

They have structured play

None of the above

Other

My child plays with toys by

(please check any and all that apply for Child #4)

Looking at them

Having help from an adult

With his/her hands

Playing themselves

Playing with friends

Using toys creatively

Other