| Mother’s Name: |
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| Father’s Name: |
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| Mailing Address: |
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| City: |
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| State/Providence: |
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| ZIP / Postal Code: |
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| Country: |
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| Phone: |
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| Fax: |
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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: |
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| Nickname: |
|
| Date of Birth: |
Gender:
Female
Male |
| Diagnosis: |
|
| Language spoken at home: |
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| 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 Colorado, 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) |
