Child's Name (required)
Birthdate (required) - please provide month, day and year
Age (required)
Street address (required)
City (required)
State (required)
Zip code (required)
Child's grade and school (required)
Siblings? (required) YesNo
If yes, please list their ages
Parent 1 contact name (required)
Parent 1 Email (required)
Parent 1 cell (required)
Parent 1 contact preference CellEmail
Parent 2 contact name
Parent 2 Email
Parent 2 cell
Parent 2 contact preference CellEmail
Emergency contact name (required)
Emergency contact phone (required)
Please describe any social concerns:
Does your child have any food or medical allergies? YesNo
If yes, please list
Does your child have any behavioral challenges (including, but not limited to aggression, oppositional behavior)? If so, please describe in detail:
Please list any medical concerns we should be aware of:
Please describe your child’s interests:
Please describe any potential sources of anxiety, fear, or distress for your child:
What motivates your child to follow instruction?
Please share any other information that you think is important for us to know about your child:
How did you hear about The Friends Grow Friends Foundation, Inc.: Word of mouthSocial mediaSchool/TeacherOther - please list below
Other:
Payment
The fee for this program is $180 for 6 sessions. Payment must be received in full prior to the start of each 6-week session. I am paying by check*. Please make checks payable to The Friends Grow Friends Foundation, Inc. for $180 I am paying by cash I am paying by credit card or PayPalvia the Friends Grow Friends website I am paying by Venmo (@TheSocialSmartsFoundation-Inc)
*There will be a $34 fee for returned checks
Registration will not be guaranteed until we have received payment in full. The class is first come, first serve, and registration closes on September 19th, 2019.
RELEASE/PICKUP AUTHORIZATION Please provide the name, number, and address of each person who you are authorizing to drop off or pick up your child at The Friends Grow Friends Foundation, Inc. social skills group.
We must be notified by phone or email before pickup that one of these authorized individuals, other than the child's parent, will be picking up your child. The individual picking up your child will be asked to show a valid form of ID (i.e. driver's license) before we release your child to them.
I understand that participants in this social skills program will not be permitted to leave with anyone other than the person(s) I have listed below.
Pickup contact name (1)
Pickup 1 Email
Pickup 1 cell
Pickup contact name (2)
Pickup 2 Email
Pickup 2 cell
Pickup contact name (3)
Pickup 3 Email
Pickup 3 cell
Signature required (use mouse or finger to sign)
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