Summer Programs 2019 Registration Form
Please complete this to register for our summer programs!
Email address *
Name of person completing this form:
Your answer
Name of Child enrolling:
Your answer
Date of Birth of Child enrolling:
MM
/
DD
/
YYYY
Are you a current patient?
Phone numbers:
Your answer
Emergency Contact, names and cell phone numbers (please list 2):
Your answer
Which program(s) are you enrolling for?
Please list any allergies
Your answer
What skills would you like your child to improve on during this experience?
Your answer
What types of incentives motivate your child?
Your answer
What are your child's favorite play activities?
Your answer
Please list any medical diagnosis your child has:
Your answer
Is there anything else you would like us to know that may be helpful in working with your child?
Your answer
How will you be providing your $50 deposit to hold your spot?
Do you have any other questions for us?
Your answer
A copy of your responses will be emailed to the address you provided.
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