Armour Dance Theatre Summer Registration 2021

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Please fill out the registration form below. Please note we will ask you to provide us with an email and password for your account with Armour Dance Theatre. For Adult students please put "N/A" under child information

STUDENT INFORMATION

First Name *

Middle Name

Last Name *

Child's Date of Birth *

YYYY

Child's Gender *

Female

Male

Prefer not to say

Miami-Dade County Public School ID # *

Child's Current School *

Is your child proficient in english? *

Yes

Other languages spoken at your home *

Spanish

Haitian Creole

None

Other:

Child's Ethnicity *

Hispanic

Haitian

Other:

Child's race (select only one) *

American, Indian, or Alaskan

Asian

Black or African American

Pacific Islander

White

Multiracial

Other:

Grade *

Does child have health insurance? (ex., private insurance, KidCare, Medicaid) If not, we may be able to help you find affordable coverage – call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.) *

Yes

Child's primary caregiver (full name)

Primary caregiver email address *

Primary phone number *

Getting to know you.

We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child…

What are the main ways in which your child communicates? (Mark all that apply)

Speaks and is easily understood

Speaks but is difficult to understand

Uses communication devices like pictures or a board

Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking

Uses sign language

Uses sounds that are not words like laughing, crying or grunting

What, if any, help does your child receive at this time? (Mark all that apply) *

Behavioral therapy or services

Counseling for emotional concerns

Daily medication (not including vitamins)

Occupational therapy (OT)

Physical therapy (PT)

Special education services in school

Speech/language therapy

None of the above

Required

What conditions does your child have that are expected to last for a year or more? (Mark all that apply) *

Autism spectrum disorder

Developmental delay (only if under age 5)

Intellectual/developmental disability (over age 5)

Hearing impairment or deaf

Learning disability (school age)

Medical condition or illness

Physical disability or impairment

Problems with aggression or temper

Problems with attention and hyperactivity

Problems with depression or anxiety

Visual impairment or blind

None of the above

Required

If you marked “None of the above” on the previous question, please skip the next two questions and sign below. If you marked any other answer on the question above, please answer the remaining questions and sign below.

Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do?

Yes

Clear selection

To support your child’s successful participation in this program, in what areas might s/he need extra assistance?

No specific help needed

Holding a crayon/pencil, writing, using scissors or other fine motor tasks

Sports or physical activities like running or other gross motor tasks

Managing feelings and behavior

Academic, learning or reading activities

Adapting activities to take into account a visual or hearing impairment

Using assistive device(s) like a wheelchair, crutches, brace or walker

Personal services like help with feeding, toileting or changing clothes

Other:

Please tell us anything else you think it is important for us to know about your child:

Confirmation

If you are interested in other services funded by The Children’s Trust, please call 211 or visit www.thechildrenstrust.org. For special needs resources for your child, visit www.advocacynetwork.org or www.thechildrenstrust.org/cwd

I give my permission for this information to be submitted to The Children's Trust for program quality and evaluation purposes. The Children’s Trust provides funding for the program.

Digital Signature *

YYYY

Email *

Address *

City/State/Zip *

Phone Number *

Parent #1 First/Last Name *

Parent #1 Phone Number *

Parent #2 First/Last Name *

Parent #2 Phone Number *

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