Summer Group Inquiry

Summer Group Inquiry
Child's Name

First Name Last Name
Birth Date

Month Day Year
Gender
Child's Mother /Guardian 1

First Name Last Name
Preferred contact number

Area Code Phone Number
E-mail
Please choose weeks you would like to attend:

Week 1: July 13th and 15th Week 2: July 20th & 22nd Week 3: July 27 & July 29th Week 4: August 3rd and 5th Week 5: August 10th and August 12th Week 6: August 17th & August 19th
Does your child currently receive services ?

Yes No No, but I have concerns
Please share a little information about your child so groups can be formed according to your child’s needs. Please share any concerns you have, what your hoping your child will get out of this group, anything that would be helpful for us to know.
Once we have enough participants and can group accordingly you will be contacted for registration. Any questions please feel free to email us or call us !
Should be Empty:

Once we have enough participants and can group accordingly you will be contacted for registration. Any questions please feel free to email us or call us !