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Growing Minds
Comprehensive Registration Form

 

Mother’s Name:
Father’s Name:
Mailing Address:
City:
State/Providence:
ZIP / Postal Code:
Country:
Phone:
Fax:
Email Address:
* Required Field

Please enter your full email address
(example: yourname@yourisp.net)
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 for available dates: 1-561-748-9697

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.)   Relationship:
  Relationship:
  Relationship:
  Relationship:
  Relationship:
  Relationship:

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

Please enter email address again:
* Required Field
Give a brief history of your child’s development.
List any prior training or programs (to help your child) that you and /or your spouse have attended. Include the method and/or name of the organization that provided the training and your dates of attendance.
Do you
currently have a home-based program for your child (or have you tried one in the past)?
Yes     No     If yes, please describe the program: methods used, approximate number of hours per week, number of people involved, how long you have been doing it, etc. If you no longer do the program, when and why did you stop?  
Give a brief description of your child’s current development in terms of...
Language:
Fine Motor:
Gross Motor:
Social Skills:
Self Help Skills:
Please enter email address again:
* Required Field
Does your child attend school? Yes     No     If yes, please indicate how many hours per week, what type of school / class, number of students in the class, etc. Do you intend to keep your child in this program while doing Growing Minds? 
Does your child have any medical conditions or physical limitations that we should be aware of?
Yes   No      If yes, please explain fully.
Is your child currently on medication? Yes   No      If yes, please explain fully.
Does your child have special dietary needs? Yes   No      If yes, please explain fully.
Does your child ever behave in ways that are self-injurious or physically aggressive towards others? Yes   No      If yes, please describe the behavior and the frequency and intensity with which it occurs.
What about being with your child do you enjoy most?
What do you find most difficult about your being with your child?
What are your goals for this training?
Is there any additional information you believe would be useful for us to know?

Cancelation Policy

If you cancel This program: You can choose between a refund or credit for future services if you cancel with 120 days’ notice. If you give 119-60 days notice, you’ll receive a credit for future services. If you give less than 60 days notice, no credit or refund will be given, unless family medical emergency can be substantiated, in which case we will issue a credit only.

In all these circumstances, we will attempt to schedule another family in your place. If we are successful, we will issue you a refund. All cancellations and program date changes are subject to a non-refundable $250 administrative fee.

In addition, the cost of any bank or credit card charges incurred for receiving and refunding your payment will be subtracted from the refund.

Registration Downpayment

Payment: A deposit of $1,000 is due upon registering. A second payment of $3,500 is due 120 days prior to the 4-Day program. The balance of $4,700 is due 60 days prior to the 4-Day program. Fees can be paid by check or credit card (Visa or MasterCard). Checks from outside the US must be international money order or cashiers check payable in US currency only.

I am sending you a check or money order for $1,000. (Payable in US funds).

Please charge the $1,000 deposit to my: MasterCard   Visa
Credit Card Number: 
Expiration Date:  (month/year: 00/00)