Winter 2019 Social Skills Registration Form
5:00-6:30 pm on Tuesdays from January 29-March 5, 2019

$375 for 6 sessions

Provided for boys and girls ages 6-10.

Seats are limited. Please submit your registration form as soon as possible to secure your child's spot in the group. Once the group has filled we will send you an invoice.

Please call or email us with any questions www.flipconsultants.com

We look forward to working with your child!

Email address *
Child Name *
Your answer
Date of Birth *
Your answer
Age *
Your answer
Gender *
Current Grade *
Your answer
School Child Attends *
Your answer
Parents' Name *
Your answer
Address *
Your answer
Parents' Email Address *
Your answer
Parents' Phone Number *
Your answer
Emergency Phone Number *
Your answer
Referred by *
Your answer
Allergies *
Your answer
Medications *
Your answer
Is your child in a regular education classroom 80% each day? *
Please provide information regarding previous evaluations, testing or diagnosis *
Your answer
Child's Strengths *
Your answer
Areas of Concern *
Your answer
Parent Goals for Group *
Your answer
Child's Interests *
Your answer
I hereby give permission for Flip Consulting and Counseling to seek medical attention in case of an emergency if I am not available. I take responsibility for using personal insurance to cover any accidents incurred by my child while attending Flip Consulting and Counseling camps or groups. *
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