Sprouted Roots Speech Sound Yoga - Winter Series 2019
Grade: Kindergarten (ages 5 & 6)

Dates: January 28th, February 4th, February 11th, February 18th, February 25th
Snow make up day - March 4th

Time
5:30- 6:30 PM

Location
Portland Pediatric Acupuncture
1703 SW Clay Street
Portland, OR 97214
Email address *
Child's First & Last Name *
Your answer
Child's Date of Birth *
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Your First & Last name *
Your answer
Your cell phone number *
Your answer
Emergency Contact Name & Phone Number *
Your answer
Which sounds does your child struggle to pronounce correctly? *
Your answer
What are your child's strengths? *
Your answer
Does your child receive special education services or private speech therapy?
If you child does receive special education services or private speech therapy please name the school or clinic
Your answer
Does your child have any food or fragrance allergies or sensitivities? If so please list.
Your answer
Is there anything else you'd like to share with us? We look forward to meeting your child!
Your answer
How did you hear about Sprouted Roots Therapy & Wellness? *
Payment Policy
Cost of the 5-week series is $150.00
After we review your registration information, we will send you a square invoice for the cost of the 5 - week series.
Payment is due within 2 business days of receiving Square invoice.

Unfortunately, we are unable to offer refunds for cancellations or missed classes for any reason.
If your child needs to miss a class due to illness, please contact us as we will provide you with the lesson plan and activities from the class missed.
Acknowledgement of Payment Policy *
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