Summer Programs 2019 Registration Form
Please complete this to register for our summer programs!
Name of person completing this form:
Name of Child enrolling:
Date of Birth of Child enrolling:
Are you a current patient?
Emergency Contact, names and cell phone numbers (please list 2):
Which program(s) are you enrolling for?
June 17-21: Preschool Language Boost
June 24-28: Social Butterflies-Basic Conversation Skills
July 15-19: AAC Club
July 22 - 27: Rhyme Time, Sight Words, and Books, Oh My!
July 29-August 2: Fun with Food: Picky Eaters Club
August 5-9: Victories and Variables (Advanced Conversation Skills)
Please list any allergies
What skills would you like your child to improve on during this experience?
What types of incentives motivate your child?
What are your child's favorite play activities?
Please list any medical diagnosis your child has:
Is there anything else you would like us to know that may be helpful in working with your child?
How will you be providing your $50 deposit to hold your spot?
Mail or drop off a check or cash
Please email me an invoice I can pay online
Do you have any other questions for us?
A copy of your responses will be emailed to the address you provided.
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