Child's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I Acknowledge There is a $50 Anuunal Fee to Hold a Session . $50 Annual Fee for Summer Program *

$50 Deposit

NEW CLASS Checkbox - Saturday 9:15 -10:45 class

Ages 3- 8 A mix of social skills and music and movement class!

9:15-10:45 Class

Checkbox 1 Social Skills Class Saturday 11:00 AM - 12:30 PM

Option 1 Social Skills Saturday 11 AM-12:30 PM

Checkbox 2 Social Skills Class Tues 4:00-5:30 PM

Option 2: social skills classes Tues) 4:00 PM-5:30 PM

Checkbox 5 August Summer Program

5 weeks (July 29th - August 30th

Week 1 July 29th- August 2nd

Week 2 August 5th- August 9th

Week 3 August 12th- August 16th

Week 4 August 19th- August 23rd

Week 5 August 26th-August 30th

Part Time

Checkbox 6 - Private Therapy Sessions

Private Therapy

Haircut Exposure & Toleration Program

Food Exposure & Toleration Program

Parent(s) Name

First Name

Last Name