Community Class Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Be sure to register for Mosaic Therapy Collectives FREE and fully inclusive series, Musical Learning with Lanny! Please take a few moments to answer these brief questions so we can continue offering these programs. See you there : )

Parent/ Guardian Name: *

Child/ Children's Name(s) *

Child/ Children's Ages)

Phone Number

Email *

Does your child have a disability &/or any additional support needs we should know about? *

(For grant-funding data collection purposes) Please identify:

Household income

less than $35,500

$35,000 - $47,900

$48,00 - $79,000

$94,800 - $128,000

$120,000+

For grant-funding data collection purposes, please identify:

Family size

Given the cost of living in Santa Barbara County, would you consider yourself:

High Income

Moderate Income

Low Income

Clear selection

I identify my ethnicity as:

Asian

Black/ African

Caucasian

Hispanic/ Latinx

Native American

Pacific Islander

Other

Prefer not to answer

Does your child have a diagnosis of:

ADHD

Autism Spectrum Disorder

Dyslexia

Dyscalculia

Dyspraxia

Sensory Processing Disorder

Central Auditory Processing Disorder

Non-Verbal Learning Disability

Visual Perceptual/ Visual Motor Disorder

Language Disorder

Deaf/ Hard of Hearing

Physical/ Motor Disability

Other Health Impairment

Specific Learning Disability

Other

Clear selection

How did you hear about us?

Thank you for registering for the event! We look forward to seeing you there : ) Anything else you would like to share with us?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Connecting Dots Speech Therapy.

Does this form look suspicious? Report

Forms