NEW Write On Registration Form 2017
Please complete the form below to apply for Write On 2017. Email Angie Earnhardt at angie@centerfordevelopingkids.com with any questions regarding the program or this application.
Child's Name: *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Age in June 2017 *
Your answer
Grade your child will have completed in June 2017 *
Your answer
Child's Gender *
Address *
Your answer
Parent's Names *
Your answer
Email Address *
Your answer
Primary Phone # *
Your answer
Emergency Contact Person *
Your answer
Emergency Contact Phone # *
Your answer
Write On Registration Information
Monday - Friday 1:15 - 3:00 pm
Early Bird Registration (Due June 2, 2017) $275 per week
Registration (Due July 24, 2017): $330 per week
One time, non-refundable registration fee: $50
Confirm Dates below *
Required
Funding Source: Please check how you will be paying. *
Required
Registration Fee: A non-refundable registration fee is required to complete your registration and reserve a spot for your child. Please select how you will pay this fee. Contact Shawn at 626 564-2700 to pay. *
Please check all that apply *
Required
Enrollment Policies and Consent Forms
Consent for Release of Information: Provide the name and contact information of a teacher or therapist who has worked with your child in a group. *
Your answer
Center for Developing Kids, Inc. has my permission to contact the person above to discuss my child's ability to participate in a group. *
Person authorized to pick up child other than parents *
Your answer
Phone number of person authorized to pick up child other than parents *
Your answer
Physician Name, Medical Insurance, & Policy Number *
Your answer
List any allergies, medications, and or special dietary needs of your child *
Your answer
Consent to Photograph *
Enrollment Policy: There will be no refund or make-up days for any missed days by any participant during the session. All registration forms and payments must be received by Center for Developing Kids by June 2, 2017 for Early Bird Registration or July 24, 2017 for regular registration. I give my permission for my child to participate in sensory motor, craft, and cooking activities. I understand there will be a $1.00 per minute late fee for pickups after 3:00 pm. In the event I cannot be reached in an emergency, I hereby give my permission to the physician named above or the one selected by Center for Developing Kids and authorize staff members to secure treatment for my child as named above. Center for Developing Kids may arrange for an ambulance or paramedic to take my child to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the child, at my expense. I understand this form does not guarantee my child's enrollment. I will be contacted and informed if my child has been accepted to Write On. *
Required
Can your child? Answer the following questions *
Yes
No
Sit at a table and show interest in drawing
Draw simple shapes
Draw recognizable shapes
Trace letters
Copy letters
Copy from a model
Write name
Print letters from memory
Read
Write a sentence
How did you hear about Write On
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