JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Registration Form for After-School Social Groups
Please complete this form to register your child for one of our After-School Social Groups.
For questions, please contact us at 205-957-0298 or
info@mitchells-place.com
.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Child's Name:
*
Your answer
Child's grade in 2021-2022 school year
*
Your answer
Child's Date of Birth:
*
MM
/
DD
/
YYYY
Child's Legal Guardian(s):
*
Both Birth Parents
Birth Mother
Birth Father
Adoptive Parents
Department of Human Resources
Other:
Guardian's Name (first and last):
*
Your answer
Name of other Guardian (if single parent, please put N/A):
*
Your answer
Contact Phone Number:
*
Your answer
Primary Address:
*
Your answer
Email Address:
*
Your answer
Secondary or Work Phone:
*
Your answer
Secondary or Work Email Address:
*
Your answer
Day Attending:
*
Tuesday (2nd and 3rd grade)
Wednesday (4th and 5th grade)
Thursday (K- first grade)
Option 1
Clear selection
Option 1
Clear selection
Referred by:
Your answer
What school does your child currently attend?
*
Your answer
Does your child currently receive school services?
*
Choose
Yes
No
Option 1
Clear selection
Does your child have an IEP or 504?
*
Choose
Yes
No
Child's Diagnosis:
Autism
Asperger's
PDD- NOS
ADHD
ADD
Other:
Clear selection
Who made the diagnosis (name of doctor):
*
Your answer
When was the diagnosis made?
*
MM
/
DD
/
YYYY
Is your child on any special diet? (If yes, please include details).
*
Your answer
Does your child take any medications?
*
Yes
No
Does your child have any allergies? (If yes, please list them).
*
Your answer
Does your child have “outbursts” or “meltdowns” due to anger, frustrations, and/or sensory overload? (If yes, please describe what the behavior looks like.)
*
Your answer
Is your child typically compliant with adult demands? (If no, what are some strategies you have used that gain compliance?)
*
Your answer
Siblings (please include name, age and any learning/medical conditions):
*
Your answer
Describe the concerns you have that prompted your referral (for example: behavioral problems, problem solving skills, personal/social skills, speech or language development).
*
Your answer
Describe your child’s play/social skills:
*
Your answer
What are your child’s special interests?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
