Clone of Parent Consultation Information Form

PARENT MEMBERSHIP REGISTRATION FORM
Today's Date

MonthDayYear
Email
example@example.com
Parent/ Guardian Name

First NameLast Name
Parent/Guardian Mobile Number
Format: (000) 000-0000.
Child's Name

First NameLast Name
Child's Date of birth

MonthDayYear
Postal Address
Nationality
Sibling 1

GenderDOB
Sibling 2

GenderDOB
Benefits:

Parent membership of the association valid for one year. The membership will entitle you to the following:
- Parent Membership for one year
- One Parent Consultation per year
- 10% discount on Social skills registration for your child
- 10% discount on Summer Camp registration for your child
- Monthly newsletter with new information on upcoming events
- Parent coffee mornings with one of our psychologists

Payment

Parent Membership Fee

150.00 CHF

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Chemin du Pommier 42 | 1218 Le Grand-Saconnex | Kyoto Building | 3rd Floor

Telephone: 022 788 21 02 - http://www.allspecialkids.org - info@allspecialkids.org
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