Summer Registration Form 
Please fill out one form per child you are signing up
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Email *
Your Name *
Your Phone Number:  *
Does your child receive any services (B23, OT, Speech, PT, etc)?  *
Anything that I should know? 
Examples: My child uses ASL to communicate. My child has a peanut allergy. My child has a medical diagnosis you should be aware of. 
 *
Your Child's Name *
Your child's DOB
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DD
/
YYYY
What sessions would you like to sign up for? Check all that apply:  *
Required
What classes are you signing up this child for?  *
Required
Questions, Comments, or Concerns? Any requests for groups outside of age ranges or something else you'd like to see? 
Will you be signing up another child?  *
Please read and acknowledge to the following statement: 

I understand that these groups are not therapy, but are a fun enrichment opportunity.  I understand that while a speech therapist by profession is running this group it is not billable through my insurance. 
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