Registration Form for After-School Social Groups
Please complete this form to register your child for one of our After-School Social Groups.

For questions, please contact us at 205-957-0298 or info@mitchells-place.com.
Child's Name: *
Your answer
Child's Date of Birth: *
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Child's Legal Guardian(s): *
Guardian's Name (first and last): *
Your answer
Name of other Guardian (if single parent, please put N/A): *
Your answer
Contact Phone Number: *
Your answer
Primary Address: *
Your answer
Email Address: *
Your answer
Secondary or Work Phone: *
Your answer
Secondary or Work Email Address: *
Your answer
Day Attending: *
Referred by:
Your answer
What school does your child currently attend? *
Your answer
Does your child currently receive school services? *
Does your child have an IEP or 504? *
Child's Diagnosis:
Who made the diagnosis (name of doctor): *
Your answer
When was the diagnosis made? *
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Is your child on any special diet? (If yes, please include details). *
Your answer
Does your child take any medications? *
Does your child have any allergies? (If yes, please list them). *
Your answer
Does your child have “outbursts” or “meltdowns” due to anger, frustrations, and/or sensory overload? (If yes, please describe what the behavior looks like.) *
Your answer
Is your child typically compliant with adult demands? (If no, what are some strategies you have used that gain compliance?) *
Your answer
Siblings (please include name, age and any learning/medical conditions): *
Your answer
Describe the concerns you have that prompted your referral (for example: behavioral problems, problem solving skills, personal/social skills, speech or language development). *
Your answer
Describe your child’s play/social skills: *
Your answer
What are your child’s special interests? *
Your answer
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