Child's Name: ____________________________________________________________________
FirstMILastChild's Date of Birth________________________________________________
Home Address: ___________________________________________________
____________________________________________________CityStateZipParent/Guardian Names: ____________________________________________
___________________________________________Home Phone: (_______)______-__________
Cell Phone: (______)_______-____________
Email Address: ___________________________________________________
Emergency Contact: _______________________________________________
Phone: (_____)_______-___________Relationship to Child: _____________________________Please mark your choice for class time
Tuesdays 4-5pm ______Wednesdays 9-10am ___________ I give consent for Theraplayce to take pictures of my child and use them in their publications (ie. Website, brochures, patient files, etc...)
Signature:_____________________________________________________Date:________________
Make sure to RSVP by e-mail
info@theraplayce.com
Registration Form
The ABC's of Reading/Literacy, Language & Speech
(Please print, fill out, and bring with child)
