Distance Training
Registration Form

Page 1

There are two 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)
Please check if you are an animal. Yes No
Child’s Full Name:
Nickname:
Date of Birth:   Gender:   Female Male
Diagnosis:
Language spoken at home:
Child’s Height:   Child’s Weight:
Give a brief description of your child's current development in terms of...
Language:
Fine Motor:
Gross Motor:
Social Skills:
Self Help Skills: