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LNC Registration Form

Meeting Times: To be determined

REGISTRATION is required

Start Date: TBD

Duration: Tailored to each client.

Program Overview: Our program is designed to serve as a bridge between home and elementary school, providing children with learning strategies and the confidence to advocate for themselves in various community spaces. By focusing on both academics and social skills, we help children build healthy relationships. The program is structured into three tiers: Individual Growth, Social Development Growth, and the Discovery Stage.

Who Can Participate: Children ages 4-12

For more information, contact us at (714) 833-3197 or admin@themosaicmovement.com

Email *
Minor's Full Name / Nombre completo  *
Minor's Address / Dirección  *
Minor's Date of Birth / Fecha de nacimiento
 *
Minor's Gender/ Género del menor *
Minor's Ethnicity/ Origen étnico del menor *
Name of Parent/Legal Guardian 1/ Nombre del padre/madre/tutor legal 1
 *
Phone Number of Parent/Legal Guardian 1/ Número de teléfono del padre/madre/tutor legal 1
 *
Email of Parent/Legal Guardian 1/ Correo electrónico del padre/tutor legal 1
 *
Preferred Method of Contact of Parent/Legal Guardian 1/ Método preferido de contacto del padre/tutor legal 1 *
Does the minor reside with Parent/Legal Guardian 1?/ ¿El menor reside con el padre/tutor legal 1? *
Marital Status of Parent/Legal Guardian 1/ Estado civil del padre/madre/tutor legal 1
 *
Parent/Legal Guardian 1: Are there any court orders in place?/ Padre/tutor legal 1: ¿Existe alguna orden judicial vigente?
 *
Special Accommodations  *
Answer all questions and ensure that all information is provided. If anything is missing, your application will be considered incomplete.

Please provide the following information:

- Does your minor have a diagnosis?  
- Diagnosis:  
- Please share any additional information staff should know about your minor’s diagnosis.

_________________________________________________________

Responda a todas las preguntas y asegúrese de proporcionar toda la información solicitada. Si falta algún dato, su solicitud se considerará incompleta.


Proporcione la siguiente información:


- ¿Su hijo menor de edad tiene algún diagnóstico?

- Diagnóstico:

- Comparta cualquier información adicional que el personal deba conocer sobre el diagnóstico de su hijo menor de edad.

Name of Parent/Legal Guardian 2/ Nombre del padre/madre/tutor legal 2 *
Phone Number of Parent/Legal Guardian 2/ Número de teléfono del padre/madre/tutor legal 2 *
Email of Parent/Legal Guardian 2/ Correo electrónico del padre/tutor legal 2 *
Preferred Method of Contact of Parent/Legal Guardian 2/ Método preferido de contacto de los padres/tutores legales 2 *
Does the minor reside with Parent/Legal Guardian 2?/ ¿El menor reside con el padre/tutor legal 2? *
Select Preferred Location/ Seleccionar ubicación preferida *
School District / Distrito escolar
Current School Name/ Nombre actual de la escuela
Grade Level/ Nivel de grado
Please list at least three interests your minor has./ Por favor, enumere al menos tres intereses que tenga su hijo menor. *
Does your minor participate in any extracurricular activities? Please share 1-2 activities./ ¿Participa su hijo menor de edad en alguna actividad extracurricular? Por favor, mencione 1 o 2 actividades. *
Would you like your minor to undergo an assessment to better understand their developmental progress?/ ¿Le gustaría que su hijo menor de edad se sometiera a una evaluación para comprender mejor su progreso en el desarrollo?
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Has the minor been a victim of bullying?/ ¿Ha sido el menor víctima de acoso escolar? *
Which areas do you feel your minor could benefit from or may require further growth and development in? / ¿En qué áreas crees que tu especialidad secundaria podría beneficiarse o podría requerir un mayor crecimiento y desarrollo?
 *
Required
What inspired you to enroll your minor in the LNC program?/ ¿Qué te inspiró a matricularte en el programa LNC como asignatura secundaria? *
How did you hear about us?/ ¿Cómo nos conociste? *
Is there anything else you would like us to know?/ ¿Hay algo más que desee que sepamos?
A copy of your responses will be emailed to the address you provided.
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