Distance Training Program
Registration Form

Thank you for registering for the Growing Minds Distance Training Program. In order to better serve you we have placed this registration form online. The information requested below is quite extensive. It will help us to create the best program possible for you and your child.
PrintYou may want to print out this form, gather the information, then return later to this page and enter the information. You can also fax this form to us at 1-561-748-6543.

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)
Child’s Full Name:
Nickname:
Date of Birth:   Gender:   Female     Male
Diagnosis:
Language spoken at home:
Child’s Height:   Child’s Weight:
Please answer the following questions:
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:
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.
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?

Registration Information

Payment: A deposit of $500 is due upon registering. A second payment of $2,700 is due prior to your evaluation. 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. Cancellation Policy

I am sending you a check or money order for $500.    (Payable in US funds).

Please charge the deposit of $500 to my:   MasterCard      Visa
       Credit Card Number: 
       Expiration Date:  (month/year: 00/00)