Family Portraits Waiting List
This event is currently full. If we get any cancellations we will contact families that fill out this form. Thank you.


Family Portraits 2021
Saturday, October 2, 2021
9:00 AM – 12 PM
The Gardens at Hippley Village, Columbiana, OH
Sessions: 10 minute mini-sessions (outdoor sessions only)
Event is sponsored by: Proactive Behavior Services
Photography services courtesy of: Jen's Photographic Memories


Covid Requirements:
Please take your temperature the morning of the event to make sure everyone is well. Also if someone in the family isn't feeling well, please cancel even if it is last minute. Cancel by text to: 330-333-9609 or email: info@autismmv.org
We are not liable as a result of any exposure to covid. A covid liability waiver is to be e-signed by all.
Read all the requirements HERE
Accept Covid Terms and Conditions


* Required Field

*Parent's or Caregiver's Name(s):


*Address:
*City:
*State:
*Postal Code:
*Phone Number (Cell):
Phone Number (Other):
*Email Address:
(to include you on future event mailings)
Preferred Contact Method:
Home, Cell, Other, Text, Email
*Preferred Photo Session Time?


Children Information:
 
*Name:
*Age:
*Diagnosis:
Name:
Age:
Diagnosis (if applicable):
Name:
Age:
Diagnosis (if applicable):
Name:
Age:
Diagnosis (if applicable):
Name:
Age:
Diagnosis (if applicable):
Name:
Age:
Diagnosis (if applicable):


What types of programs would you like the Autism Society of Mahoning Valley to provide for your child and/or for your family? :


I give permission and consent to allow photographs to be taken during Autism Society of Mahoning Valley activities. I further give permission and consent that any such photographs may be published and used by Autism Society of Mahoning Valley and its agents, to illustrate and promote its programming and fundraising efforts.

Furthermore, I grant the Autism Society of Mahoning Valley, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize the Autism Society of Mahoning Valley, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Autism Society of Mahoning Valley may use such photographs of my family with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above:
By Submitting this form, I am registering for the event and accepting the terms of this release form.

Please read our disclosure: The Autism Society reserves the right to cancel registration to any parties that have had one or more no contact cancellations in the past two years. One member of the family needs to have a diagnosed disability of autism or similar diagnosis to participate.