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Summer Programs 2020 Registration Form
Please complete this to register for our summer programs!
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Email
*
Your email
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?
Yes
No
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Phone numbers:
Your answer
Emergency Contact, names and cell phone numbers (please list 2):
Your answer
Which program(s) are you enrolling for?
June 22-26: Think Social! Starting the Detective Agency. Ages 5-7.
June 29-July 3: Think Social! Super Detective. Ages 5-7
July 6-9: Preschool Language Boost. Ages 3-5
July 14-17: Think Social! Starting the Detective Agency. Ages 7-10
July 20-24: Think Social! Super Detective. Ages 7-10
July 27-31: Think Social! Starting the Detective Agency. Ages 10-13
Aug 3-7: Think Social! Super Detective. Ages 10-13
Other:
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?
Mail or drop off a check or cash
Please email me an invoice I can pay online
I paid on the website:
https://www.virginiaspeechtherapy.com/pay-online.html
Other:
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I understand that this program is not appropriate for students with significant cognitive delays, significant oppositional/defiant behavior, and/or a history of aggression or high likelihood of aggression.
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I understand and agree.
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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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