Abilities EI Registration Packet
This form helps the teachers plan a program to meet the needs of the children in each class. If more space is needed, please contact teachers directly. Information will be kept confidential.
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Email *
I am enrolling my child in the following Early Intervention class *
Required
Student's Last Name
Student's First Name
Nickname
Child's Date of Birth *
MM
/
DD
/
YYYY
Gender *
Name of Primary Contact *
Primary Contact Phone Number *
Primary Contact Email *
Name of Secondary Contact *
Secondary Contact Phone Number *
Secondary Contact Email *
Name and Number for Child Care Provider if applicable
Photo permissions: I grant permission for my child's picture to be
 *
Does your child have any allergies? If yes, please specify on Emergency Forms.
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Does your child have any other medical conditions that the teachers should be aware of? If yes, please specify on Emergency Forms.
 *
Has your child received any special services (PT, OT, Speech, etc.)? If yes, please expand.
Do you have any concerns about your child's development (cognitive, social, emotional, physical)?
Who lives in the home with your child (names, ages of other children)? *
What language(s) does your child speak? Primary language spoken in the home if other than English? *
Please include any other information you feel would be important for the teacher to know in order to help your child have a successful school experience. (Previous play group/school experiences, ease of separation from caregiver, fears, soothing and discipline strategies, favorite activities, etc.)
 *
The following items are required for registering your child: 
By "signing" below you are confirming that all of the information provided above is true and has been completed by the parent/legal guardian of the child being enrolled.
 *
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