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Registering for:
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Sensory & Social Saturdays
Start Date
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Month
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Day
Year
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1 - Student's Full Name
*
First Name
Last Name
2 - Student's Date of Birth
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Month
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Day
Year
Date of Birth
Grade
*
Please Select
Pre K
K
1
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3
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6
Schedule your 1 on 1 intro meeting with RBT to discuss your child's needs
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PARENT INFORMATION
Mother Full Name
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First Name
Last Name
Mother Email
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Mother Phone Number
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Father Full Name
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First Name
Last Name
Father Email
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example@example.com
Father Phone Number
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Home Address
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Street Address
Street Address Line 2
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PAYMENT
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Monthly: Sensory & Social Saturdays
90 Minute weekly sessions
$
180.00
Drop In: Sensory & Social Saturdays
60 Minute session
$
22.00
Credit Card Details
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Last Name
Credit Card Number
Security Code
Card Expiration
Enrollment Agreement
Please review and sign
Signature
*
Date of Consent
*
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Month
/
Day
Year
Date
How did you hear about this program
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Back to School Fair
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