First Choice Speech Therapy

Camp Registration

Speech and Language Camp Registration

Stay Tuned for Camp Registration for 2010.

Do you have permission to register this child in speech or language camp?
 I am the child's parent or legal guardian. *

 

What is the child's name?

What is the child's DOB?

What is the name of the parent or legal guardian?

What is the home phone number?

 What is the child's home address?

What is the parent's email address?

What is the parent's cell phone number?

When is the best time to reach the parents?

Which week will the child be attending camp?

What is the child's payment source for services?

If private insurance, who is your insurance carrier?

What are your concerns regarding your child's speech and language skills?

Are there any special considerations regarding your child?

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