We Cach Program Registration Form

We Coach Foundation: Program Registration Form

Fill out the form carefully to register for any of our programs. Please make sure to also create a member account in our website.
Participant's Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
E-mail*
example@example.com
Mobile Number*
Format: (000) 000-0000.
Emergency Contact/Guardian's Name*
Emergency contact/Guardian Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Choose the programs you want to register for:*
Social Interaction*

1

2

3

4

5

6

7

8

9

10

1 is Prefer to be alone, 10 is Very Friendly
Personal Hygiene - Ability to complete self care tasks independently*

1

2

3

4

5

6

7

8

9

10

1 is Dependent on other's assistance, 10 is Independent
Ability to pay independently *

1

2

3

4

5

6

7

8

9

10

1 is Dependent on other's assistance to handle payments, 10 is Independent
Ability to care and handle personal belongings such as a wallet, purse or phone.*

1

2

3

4

5

6

7

8

9

10

1 is Dependent on other's assistance, 10 is Independent
Ability to follow 3 steps auditory commands with minimum redirection*

1

2

3

4

5

6

7

8

9

10

1 is Dependent on other's assistance, 10 is Independent
Understanding the importance of staying in a group*

1

2

3

4

5

6

7

8

9

10

1 is Dependent on redirection, 10 is Independent
Turn taking, waiting, coping and frustration tolerance skill sets*

1

2

3

4

5

6

7

8

9

10

1 is Depend on other's assistance, 10 is Independent
Communication*

Non-verbalNon-verbal AAC DeviceNon-verbal ASLAble to communicate needs and wants with limited languageVerbalOther
If other: Please explain
Sensory Issues or other concerns - If none, please type NONE*
Share Interests or preferred activities*
Should be Empty:

We Coach Foundation: Program Registration Form