Social Squad Hosted by Better Together

Social Squad Hosted by Better Together

Please complete this form to register for Social Squad!
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date
Interested Group Dates - Social Club will be held on Monday's and Wednesday's from 12:30-3:30 PM.
My child currently receives the following services at We are Better Together, School or another location:
How does your child communicate?

Other
Diagnoses:

Other
Challenges: Please check the following challenges that describe your child
Our current adult to child ratio is approximately 1:6. Will your child need additional support?
I acknowledge that if my child needs additional support, that I will be able to provide it
What do you hope to gain from the social squad club?

Other
Other information you would like to share about your child that will help us best accommodate them during Social Squad Club.
I acknowledge that Social Squad is not a free service. I understand that the cost of participation is $60 per class or $400 for all 8 classes, and that payment is due prior to the start of the program.Social Squad is a therapeutic social skills program facilitated by licensed and certified Speech-Language Pathologists. Depending on a participant's individual circumstances, some insurance plans or Medicaid may cover all or a portion of the program cost; however, coverage is not guaranteed and families are ultimately responsible for any unpaid balance. Upon sign up we will contact you to discuss payment options. I understand that there are no refunds for missed sessions, withdrawals, or cancellations. Scholarship opportunities may be available, contact us for details.
Caregiver/Parent Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best way to contact you

Other
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you find out about our Social Squad? If it was from one of our staff please write in the staff members name.
Exciting things are coming your way! Keep an eye on your inbox for an email with all the details on what's next in your Social Club journey!
Social Squad Club Registration Fee is $25 and will cover the cost of camp t-shirt, materials, and supplies. This is a nonrefundable fee.

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Social Squad Hosted by Better Together

Exciting things are coming your way! Keep an eye on your inbox for an email with all the details on what's next in your Social Club journey!

Social Squad Club Registration Fee is $25 and will cover the cost of camp t-shirt, materials, and supplies. This is a nonrefundable fee. *

Pay with PayPal

Social Squad Club Registration Fee is $25 and will cover the cost of camp t-shirt, materials, and supplies. This is a nonrefundable fee.