KDO Dancers with Disabilities Inquiry Form
Welcome to Kids Dance Outreach!  Thank you for your interest in our Dancers with Disabilities Program!

To best serve you and your children, we require all families to go through a simple intake process. This allows us to ensure that participating students have a safe and successful experience and represent a cohesive group.

Please note that KDO is a public charity that relies on grants and individual donations. We strive to serve a diverse population and to create a culture of openness and inclusion. Our founders request demographic information from us to ensure data is consistent with their standards and guidelines from time to time. Some information included here is used solely for this purpose, and all your responses will be kept private and secure. We respectfully ask for your permission to share that information with them and hope you will let us know if you prefer not to participate in this process.

If you have any further questions, comments, or concerns, don't hesitate to get in touch with Dana Vanderburgh, Associate Director, Community Engagement & Programming (dvanderburgh@kdoutreach.org)

We look forward to getting to know you!  

Thank you!
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Email *
General Information & Contact
Please review the following information
Alternate Email Address
How did you hear about KDO? *
Student First Name *
Student Last Name *
Student Age *
Student Gender *
Pronouns Child Uses *
Is there anything about your child that you would like for us to know? If you prefer to share this information privately, attach a separate note or we can set up a time to discuss with you directly. Please know that  Kids Dance Outreach considers this private and confidential information that will only be shared with your expressed permission and guidance.  
Student's School *
Indiana County of Residence (i.e. Marion, Hamilton, etc) *
Parent/Guardian First and Last Name *
Phone Number *
Student Resides With *
Student's Race/Ethnicity *
Student identifies as:
Dancers with Disabilities Questionnaire
Please answer the following questions to the best of your ability at this time.
Child's Diagnosis *
Does your child require assistive technology and/or devices? *
If yes, please describe.
Does your child require one-on-one assistance at school? *
If yes, please describe.
Does your child have a hearing impairment? *
If yes, please describe.
Does your child have serious neck, spine, or orthopedic concerns? *
If yes, please describe.
Can your child follow instructions? *
Additional comments?
Has their pediatrician cleared them to participate in physical activity? *
If/when enrolled in the KDO Program - I consent or my child to participate in the Kids Dance Outreach Program *
Required
If/when enrolled in the KDO Program - I consent to the use of, and understand that pictures/video/interviews taken of my child during Kids Dance Outreach may be used for publicity purposes now and in the future. *
Required
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