Hammonton 4-8 form trial class | mslindsayslilrockers

Autism Movement Therapy Registration Form: Ages 4-8, Hammonton, NJ

FORM MUST BE COMPLETED BY A LEGAL GAURDIAN

CHILD'S LAST NAME

CHILD'S FIRST NAME

SEX

MALE

FEMALE

MERMAID

OTHER

PLEASE LIST ALL ALLERGIES

DOES YOUR CHILD HAVE AN EPIPEN?

YES

DOES YOUR CHILD HAVE AN INHALER

YES

PLEASE LIST ALL PHYSICAL CONDITIONS OR IMPAIRMENTS, COGNITIVE LIMITATIONS, SPECIAL NEEDS OR CHALLENGES

IS THERE ANYTHING ELSE WE SHOULD KNOW MEDICALLY ABOUT YOUR CHILD?

PLEASE SHARE WITH US ANYTHING THAT TENDS TO MAKE YOUR CHILD UPSET OR UNCOMFORTABLE. GENERALLY, WHAT ARE THEIR ACTIONS WHEN THEY FEEL THIS WAY? WHAT CAN WE DO TO HELP THEM IF THIS WERE TO HAPPEN DURING A CLASS?

GAURDIAN'S LAST NAME

GAURDIAN'S FIRST NAME

PHONE

ADDRESS

EMAIL ADDRESS

EMERGANCY CONTACT FULL NAME

RELATIONSHIP TO CHILD

EMERGANCY CONTACT NUMBER

RELATIONSHIP

IS THERE ANYTHING ELSE WE SHOULD KNOW?

Attention: Your spot will not be secured until you pay for the class *

Thanks for submitting!