Client Registration Form
Date:
MM
/
DD
/
YYYY
Client Information
D.O.B (Date of Birth) *
MM
/
DD
/
YYYY
First Name/Middle Name *
Your answer
Last Name *
Your answer
Gender *
Height ft/in (example 5.1) *
Your answer
Weight lbs. example (72) *
Your answer
Who does child live with? *
Ethnicity:
Diagnosis: *
Your answer
School Name:
Your answer
Grade *
Your answer
Special Education Program?: *
Is child performing at grade level?* *
*If no please explain
Your answer
Parents/Guardians Information
Name of Primary Custodian: *
Your answer
Relationship with child: *
Moms Name:
Your answer
Moms email
Your answer
Moms phone number:
Your answer
Dads Name
Your answer
Dads email:
Your answer
Dads phone number:
Your answer
Address (Street,City,State zip)
Your answer
In case of Emergency:
Name of emergency contact #1: *
Your answer
Relationship of emergency contact #1: *
Your answer
Phone number of emergency contact #1: *
Your answer
Name of emergency contact #2:
Your answer
Relationship of emergency contact #2:
Your answer
Phone number of emergency contact #2:
Your answer
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