Child's Nature Summer Program Intake
Please fill out this form so we can better meet the needs of your child this summer.
Email *
Child's Name
Child's Birthday
MM
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DD
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Grade in School
Parent's Name(s)
Address
Cell Phone Number
Ok to send text messages?
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Main Needs and Concerns
What are you child's strengths?
What skills would you like your child to develop through this program?
Does your child have an IEP or 504? Please explain.
Please describe your child's current school placement (name of school, type of classroom, aides, etc.)
Briefly explain child's history as it pertains to your concerns/need for intervention.
Does your child have any developmental disabilities or receive any type of therapies? Please explain.
Anything else you would like us to know?
Which program(s) is you child attending this summer?
A copy of your responses will be emailed to the address you provided.
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