Thanks for your interest in our Social Saturdays at ABA Outreach! This is a pre-registration form to express interest in the Social Saturday Meet-Up group. Upon receipt of the form, staff will follow up with you regarding whether your child is a best fit for this group and has the skills needed to benefit from our service delivery model.
We pride ourselves on individualized and differentiated instruction. We tailor each program to meet the unique and specific needs of all our students. Certain social, language and behavioral skills are necessary however, to successfully participate in this program. The below form is to provide us with more information so that we may determine whether your child is an appropriate fit at this time. In particular, Social Saturdays will concentrate on developing socialization and conversational skills. If not, we will follow up to discuss future events that will be better suited for your child.
I'm Applying for the..
Nov 16, 2019 Autumn Activities
Contact Phone Number:
Class Room Placement:
Does your child require 1:1 support in a small group setting?
Does your child use the bathroom independently?
Does your child engage in aggression, self-injury or property destruction? (within the last 6 months) *click all that apply
Aggression towards peers
Aggression towards adults
None of these
Does your child have a behavior intervention plan as part of their IEP? If yes, please identify target behaviors.
What services does your child utilize?
No services utilized
How does your child communicate?
No formal mode of communcation
Please describe your child's ability to follow directions.
Needs a lot of prompting
One step directions
Two step directions
Multi step directions
Please describe your child's attention span:
A few minutes
Please describe any vocal/motor stereotopy, preferred areas of interest, restrictive behaviors etc that may be unique to your child that you'd like us to be aware of and plan for
What are your top 3 priorities in terms of the skills you'd like to see your child gain from group?
I understand that Social Saturdays fees are non-refundable.
I agree to allow my child to participate in all scheduled activities at ABA Outreach LLC Social Saturdays, do agree to release and hold harmless ABA Outreach, LLC staff, agents, officers, and directors from any and all liability for any and all claims, demands, injuries, loss, damages, costs, expenses, actions or causes of actions of any nature for personal injury, sickness, physical or mental injuries or property damages of any kind arising in any way from my child’s participation at ABA Outreach, LLC Social Saturday events. I also agree to indemnify and hold harmless ABA Outreach, LLC staff against all civil actions or claims from harm, or disability to the named that I am the parent/legal guardian, or that are caused in whole or in part from any act having any connection with and or arising from participation in any and all activities at and during ABA Outreach, LLC Social Saturday events. Please type your full name to be used as an electronic signature.
I hereby give permission for ABA OUTREACH, LLC to have photographs and/or videos taken of my child. I understand these photos may be used for the education and training of ABA Outreach staff and clients, for external or internal publications such as newsletters and websites, and for social media, such as Facebook.
Yes to pictures
No pictures please
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