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Winter Wonderland 2023
Winter Wonderland Enrollment 2023
Saturday December 16th
Child's Information
Child's Full Name
*
Date of Birth:
*
Age
*
Current Grade
*
Current 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 (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?
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
*
What interventions have worked?
What interventions have not worked?
Winter Wonderland - December 16th
yes
no
Winter Wonderland 2023
Pre-K: 12PM-3PM *WAITLIST*
K-1st Grade: 12PM-3PM
2nd-5th Grade: 5PM-8PM
Middle School: 5PM-8PM
High School: 5PM-8PM *WAITLIST*
Submit
Payment Details
Winter Wonderland ONLY Deposit
*
Total
$
75
Credit/Debit Card
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