Program Registration Form

Social Groups & Programming

Child Name (First & Last)

Guardian Name (First & Last)

Child DOB

Child Grade

Write N/A if not applicable

OAP Number

Guardian Phone number

Please List Allegeries

Write N/A if not applicable

Email Address

Do you want to be contacted about clinical oversight from a Registered Behaviour Analyst? Registered Behaviour Analyst is required for OAP and benefit invoicing. Please note, this is an additional fee.

Yes

Which group are you enrolling for?

Little Explorers (Monday 5:30-7pm)

Kindergarden Age

Confidence Club (Tuesday 5:30-7pm)

Elementary Grade (Grade 1-5)

Game Changers (Wednesday 5:30-7pm)

Teens (Grade 8-12)

Friendship Builders (Thursday 5:30-7pm)

Tweens (Grade 6-8)

Bright Beginnings (Daytime hours)

Preschool Age

Any additional information

i.e.; goals, specific interests, triggers, helpful support strategies

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