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LOMA Speech & Language Summer Camps
Thank you of your interest in our Summer Speech & Language Groups! 
Please complete the form below. Groups are limited to 2-4 children and are formed based on age and communication goals. 

You will be contacted to confirm placement and schedule. 
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Child Information:

Child's Name: 
 *
Child's Date of Birth:
 *
Child's Age: 
 *
Parent/Guardian(s) Name(s):
 *
Email Address:
 *
Phone Number(s): 
 *
Communication Needs: 
What are your primary concerns? 
 *
Required
Has your child previously received speech therapy?  *
If yes, please briefly describe past or current services: *
Which session dates are you interested in? *
Required
Preferred session times:  *
Required
What days work best? *
Required
Program Commitment  *
Required
Payment agreement *
Required
Anything else you'd like me to know about your child? *
Thank you! 
You will be contacted shortly regarding group placement and next steps. Spots are limited and filled on a first-come basis. 
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