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Heart of Christmas Registration Form

- Ministries & Life Enrichment for Persons with Special Abilities
  
  A COMMUNITY EVENT BENEFITING
  
  Catholic Charities of Corpus Christi is excited to announce The Heart of Christmas, a special community event benefiting the Ministries & Life Enrichment for Persons with Special Abilities program.
  
  *Please note: This event is for families with intellectual disabilities who are Deaf or Blind.
- This form is not accepting responses at this time.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Gender REQUIRED Please fill out this field. Please enter valid data.
  
  Age REQUIRED Please fill out this field. Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Texting? REQUIRED Yes No Please fill out this field.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Please list the special ability REQUIRED Deaf Hard of Hearing Blind Other Please fill out this field.
  
  Comments:
  
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