Class Enrollment

Child's Information

Child's Name*

Date of Birth:*

Current Grade/School

Address*

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Parent 1 Information

Parent 1 Name*

Parent 1 Phone*

Parent 1 Email*

Best time to call

Parent 2 Information

Parent 2 Name

Parent 2 Phone

Parent 2 Email

Best time to call

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Child*

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Child's Medical Information

Allergies

Referred by

Current Medications/dosage/frequency

Current Diagnosis and or medical condition(s)

(Continued)

My child does not have a current diagnosis and/or medical condition

Child's Behavioral Information

Likes*

Dislikes*

My child needs support with:

Social behaviors ( personal space/greetings/goodbyes)

Conversational skills

Making/keeping friends and getting along (social rules/initiating/problem solving)

Emotional Regulation (labeling emotions/understanding emotions of him/herself and those of others/relaxation techniques during times of frustration or times of stress)

Other:

Please specify:

Concerns/Behaviors noted at home and or school*

Your Goals for Group

TRACK OUT CAMPS (FARM)

Track Out Camp (Farm)

I want to enroll in a Track Out Camp (Farm)

Select your Track Out Camp (Farm) Time Slot. To

TEACHER WORKDAY FUNDAY

Check below if you are interested in enrolling in a Teacher Workday Funday

I want to enroll in a Teacher Workday Funday

Select your teacher workday funday date. For multiple dates hold 'control' or 'command' and click on the dates

Winter Wonderland Experience

Check below if you are interested in enrolling in the Winter Wonderland Experience

I would like to attend the Winter Wonderland Experience

Skill Builders (2-3 yr olds) @ Farm Location

Check below if you would like to enroll in the Skill Builders (2-3yr Olds - Fridays 9:00 AM - 11:00 am, beginning Sept 10)

Yes, I would like to enroll in the Skill Builders Group

Farm Social Skill Group + Animal Assisted Therapy

Check below if you are interested in enrolling in the Farm Social Skill Group (starting Oct 11, 2021)

Yes, I would like to enroll in the Farm Social Skill Group (starting Oct 11, 2021)

Select your farm social skill group

Social Skill Group (Cary) - Time Slot Preference

Please select your top 3 choices for the time slot for your child. We will do our best to accommodate your selections.

1st Choice

2nd Choice

3rd Choice

Payment Details

Single Class Registration Deposit*

A deposit is required upon registration to guarantee you a spot in the upcoming class schedule. This amount is put toward the total payment for the classes.

Total $ 50

PAYPAL Credit/Debit Card