Child's Name *

First Name

Last Name

Parent(s) Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Checkbox - Music and Movement Classes

Ages 3- 11 A mix of social skills and music and movement class all fostering social skills devleopment - check all that apply

9:15-10:45 am Saturday Class Fall Session

4:00-5:30 pm Tuesday Class Fall Session

9:15-10:45 am Saturday Class Winter Session

9:15-10:45 am Saturday Class Winter Session

9:15-10:45 am Saturday Class Spring Session

9:15-10:45 am Saturday Class Spring Session

Checkbox Social Skills Classes ages 3-15 - check all that apply

Social Skills Classes Tuesdays 4:00 PM-5:30 PM - Fall Session

Social Skills Classes Saturdays 11:00-12:30 pm- Fall Session

Social Skills Classes Tuesdays 4:00 PM-5:30 PM - Winter Session

Social Skills Classes Saturdays 11:00-12:30 PM - Winter Session

Social Skills Classes Tuesdays 4:00 PM-5:30 PM -Spring Session

Social Skills Classes Saturdays 11:00-12:30 PM - Spring Session

Checkbox 5 August Summer Program

August 4th-August 29th

Week 1 August 4th-8th

Week 2 August 11th-15th

Week 3 August 18th - 22nd

Week 4 August 25th- 29th

Check here if also applying with Perform Care

Checkbox 6 - Private ABA Sessions

Private Therapy

Haircut Exposure & Toleration Program

Food Exposure & Toleration Program

I Acknowledge there is a $50 Annual Enrollment. 50% of your payment is due after your intake. *

$50 fee