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Legotherapy - Registration Form
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* Indicates required question
Email
*
Your email
Legotherapy Group Details
Child's Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Name(s) of Parent(s):
*
Your answer
Mobile Phone:
*
Your answer
Home Telephone:
Your answer
PO Box & Address
*
Your answer
Emergency Contact:
*
Your answer
School:
*
Your answer
Grade:
*
Your answer
Diagnosis (if applicable):
*
Your answer
Physician Name:
*
Your answer
Additional Questions / Comments / Information for our Therapists:
Your answer
Please select the group(s) you are registering your child in:
*
TOTAL AMOUNT IS DUE UPON REGISTRATION
Spring 2023 | March 21 - June 27, 2023 | Tuesdays 4-5pm | COST: $110CI per session
Summer 2023 | July 4 - August 30, 2023 | Tuesdays 4-5pm | COST: $110CI per session
Other:
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