Comprehensive Program
Registration Form

Page 1

There are three pages to the registration form. The information we ask you to provide is quite extensive in order to help us create the best custom program for you and your child.

We recommend you print out this form, gather the information, then return later to fill in the form.

Email Address:

 * Required Field Please enter your full email address
Mother’s Name:
Father’s Name:
Mailing Address:
City:
State/Providence:
ZIP / Postal Code:
Country:
Phone:
Fax:
Child lives with: Both parents   Mother    Father
Other: (please explain)
Please indicate your relationship to the child: Mother    Father    Other: (please describe)
Will both parents participate in the 4-day program? Yes     No
Will you be using a translator for the 4-day program? Yes     No

(All session are conducted in English. If English is not the primary language spoken at home, you will need to bring a translator to assist your child while parents are being trained separately. Please call us if you have questions about this.)

Available Dates

Please call 1-561-748-9697 for available dates.

Child’s Full Name:
Nickname:
Date of Birth:   Gender:   Female     Male
Diagnosis:
Language spoken at home:
Child’s Height:   Child’s Weight:
Names and ages of child’s siblings:   Age:
  Age:
  Age:
  Age:
  Age:

If children under 16 are accompanying you to Florida, you will need separate child care for them, so that your training with us can be focused on your child with special needs.

Please list the names of other adults who will participate in the 4-day program, and state their relationship to the child (e.g. grandparent, program volunteer, etc.)
Please check if you are an animal. Yes No
  Relation:
  Relation:
  Relation:
  Relation:
  Relation:
  Relation:

We can accommodate a maximum of 6 adults (age 16 or older) for the training program.