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Empowering Children of all Abilities
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Summer 2023 Staff
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Fall Enrollment PreK
Fall 2023 Session 1 PreK Enrollment
Child's Information
Child's Full Name
*
Date of Birth:
*
Age
*
Current Grade
*
Current School
*
Address
*
Separator
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
*
Separator
Child's Medical Information
Allergies (Please List)
Current Medications/dosage/frequency
Any medical diagnoses and/or medical condition (s) currently being followed by a provider regarding:
Who is your child's pediatrician?
Are you followed by any other medical providers?
Previous History
Has your child ever had a psychoeducational/ psychological evaluation either privately or by the school system?
*
If yes, please give the date last completed and who did the testing:(can give year if you don’t know exact date)
Current Supports
Providers we are currently working with and frequency: If none, please say none.
*
Does your child have a current diagnosis/diagnoses? If so please list here..
*
Does your child have a 504 plan or Individual Education Plan (IEP)? If so please list last meeting date:
*
What level of support does your child require at school:
*
Itinerant Support (Preschool)
Preschool Classroom assigned by IEP team
Resource Support (push in/Pull out services- general education setting)
Separate Setting (Specialized Classroom)
Curriculum Assistance Class (For Middle and High School)
No current supports at school
Other
Please specify:
Referred By
*
Likes
*
Child's Behavioral Information
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
*
What interventions have worked?
What interventions have not worked?
Your Goals for Group
Select Dates - 1st Choice
Monday/Wednesday/Friday 9-12pm class (12 week commitment)
Tuesday 2-4pm (2 classes)
Thursday 2-4 pm (2 classes)
Select Dates - 2nd Choice
Monday/Wednesday/Friday 9-12pm class (12 week commitment)
Tuesday 2-4pm (2 classes)
Thursday 2-4 pm (2 classes)
Select Dates - 3rd Choice
Monday/Wednesday/Friday 9-12pm class (12 week commitment)
Tuesday 2-4pm (2 classes)
Thursday 2-4 pm (2 classes)
Would you be interested in a Saturday class if staffing could be available?
Choose an option
yes
no
Winter Wonderland - December 16th *WAITLIST*
Yes *WAITLIST*
No
Submit
Payment Details
Single Class Registration Deposit* $150 NON-REFUNDABLE
*
A
$150 NON-REFUNDABLE
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
$
150
Credit/Debit Card
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