The Outdoor SPOT Registration Form

Registration Form

Join us for a therapeutic play group with nature-based components! Facilitated by a licensed speech-language pathologist and occupational therapist from Leading Therapy Home and designed for children ages 4-6, this group supports early development skills in a playful, supportive outdoor environment!
When: Monday, June 29 - Thursday, July 2 9:00-11:00 AM Where: King Oak Hill Park, Weymouth, MA
Child Information
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is your child potty trained?
Describe your child’s social skills and experiences with other children (e.g. do they attend daycare, preschool, other playgroups?)
Do you have any concerns regarding your child’s speech or language skills? If yes, please explain.
Do you have any concerns regarding your child’s motor, self-care, feeding or sensory skills? If yes, please explain.
Will your child require your (caregiver) 1:1 support to participate and stay safe within the group?
What are you hoping your child gets out of the Outdoor SPOT?
Is your child a current Leading Therapy Home client? If not, are you interested in learning more about our services?
Media Consent:

Payment

The Outdoor SPOT

June 29-July 2, 9:00-11:00

$260.00

Total

Credit Card

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature
Should be Empty:

Registration Form

When: Monday, June 29 - Thursday, July 2 9:00-11:00 AM Where: King Oak Hill Park, Weymouth, MA

Child Information

Payment*

Credit Card

Payment