Please fill all the required fields
Registering for:
*
Sensory & Social Saturdays
Select you start Date
*
-
Month
-
Day
Year
Date
Select you preffered option
*
Weekly (90 min Session)
Drop in (60 min Session)
Select you preffered drop in session time
Saturdays, 11:00 AM -12:00 PM
Select you preffered weekly session time
Saturdays, 11:00 AM -12:30 PM
Saturdays, 1:30 PM - 3:00 PM
1 - Student's Full Name
*
First Name
Last Name
2 - Student's Date of Birth
*
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Month
-
Day
Year
Date of Birth
Grade
*
Please Select
Pre K
K
1
2
3
4
5
6
Schedule your 1 on 1 intro meeting with RBT to discuss your child's needs
PARENT INFORMATION
Mother Full Name
*
First Name
Last Name
Mother Email
*
example@example.com
Mother Phone Number
*
Please enter a valid phone number.
Father Full Name
*
First Name
Last Name
Father Email
*
example@example.com
Father Phone Number
*
Please enter a valid phone number.
Home Address
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Street Address
Street Address Line 2
City
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State
Zip Code
PAYMENT
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Weekly:Sensory & Social Saturdays
Billed Monthly ($180/month)
$
180.00
Drop In: Sensory & Social Saturdays
One Time
$
35.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Enrollment Agreement
Please review and sign
Signature
*
Date of Consent
*
/
Month
/
Day
Year
Date
How did you hear about this program
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Back to School Fair
Representative called
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