Rebounders
Trampoline Groups
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Date of Birth:
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I am interested in:
Spring Session 1: March 14 - March 18, 2022, Monday-Friday, 1:00 PM-1:45 PM
Spring Session 2: March 21 - March 25, 2022, Monday-Friday, 1:00 PM-1:45 PM
Spring Session 3: March 28 - April 1, 2022, Monday-Friday, 1:00 PM-1:45 PM
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How did you hear about "Rebounders"?
Parent A's Name:
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First Name
Last Name
Home Phone:
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Area Code
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Cell Phone:
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Phone Number
E-mail
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Emergency Contact Name:
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First Name
Last Name
Emergency Contact Phone Number
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Area Code
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List any current and previous diagnoses:
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List any previous treatment at STAR Institute or other places: (include any current or previous therapies and testing)
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Please describe your concerns for your child in regards to motor skill development:
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Your child's interests:
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Describe play abilities with other children: (including siblings)
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Describe your child's currentlanguage skills: (length of sentences, how many step directions can he/she follow, does he/she answer questions, how easily can he/she be understood by peers)
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Does your child have social or behavioral challenges?
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Does your child have any allergies or other important medical conditions?
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Do you have any safety concerns re: your child on a trampoline? If yes, please explain:
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Will you be receiving Developmental Pathways funding for this group?
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