Please fill out our application

Please provide the following information so we can best understand the needs of your child. This information will remain confidential and serves to help us place your child in the most appropriate group.

Program


Parent Information

First Name


Last Name

Email


Phone

Address

City


State
Zip



Child's Information

First Name


Last Name

Date of Birth


Gender

School

Grade


Class Type

Referral

Notes

# Does your child ...  
1 Use greetings with familiar people?
2 Play, build or work on simple projects with other children?
3 Accept losing?
4 Attend to a story for at least 5-10 minutes?
5 Imitate actions of others?
6 Have the ability to state his/her interests (e.g. “I like to draw.”)?
7 Show concern for others?
8 Recognize personal space?
9 Have the ability to identify nice vs. mean actions/statements?
10 Understand facial expressions?

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