Talkin' Toddlers Program
Interest Form
Child's Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Age
*
Parent/Guardian
*
First Name
Last Name
Phone Contact Number
*
-
Area Code
Phone Number
Email
*
What are your main goals and concerns for your child?
Please indicate which options you are interested in below. Our programs director will then be in touch with you via email or phone within 1-2 business days regarding your interest. Thank you for choosing TLC! We are looking forward to working with you
M/W
T/Th
M-Th
How did you hear about Therapeutic Learning Center's Speech and Language Group?
Website
Flyer
Word of mouth
School
Facebook/Instagram
Other
Please give our Programs Administrator 1-2 business days to contact you about your submission. Thank you!
Therapeutic Learning Center
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