S.P.L.A.S.H.

Sound Play and Language Awareness Story Hour

Registration Form
Session
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's/Caregiver's Name

First NameLast Name
Address

Street Address

Apt

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
WAIVER: I agree that neither J. Cornack Therapy Group, nor Robin Williams Harnish, can be held responsible for property damage, property loss, or personal injury that may occur while attending SPLASH.
Parents Signature (Waiver):
MEDIA RELEASE: I grant permission to J. Cornack Therapy Group, and Robin Williams Harnish to use any recordings of my child (photographic, audio, or video) for public relations, and/or teaching purposes.
Parent Signature (Media Release):
Does your child have allergies? If so, please specify:
Session Information: Wednesday Mornings from 9:30 - 10:30 AM
Location:

J. Cornack Therapy Group

620 Paxton Place, Suite 102,

Lititz, PA 17543

Fee: $180.00 for 9-week session. Price is not prorated. Fee must be paid in
full for spot to be reserved.

Please note:
A mandatory parent/caregiver orientation is held via Zoom the evening
before each session begins. The same parent or caregiver who will attend
SPLASH each week should also attend this Zoom orientation. A Zoom link
will be emailed one week before the session starts.
DateTime
Note: After submitting this form, you will be automatically redirected to a secure payment page to complete your registration. Please ensure you complete the payment to confirm your spot.
Should be Empty:

WAIVER: I agree that neither J. Cornack Therapy Group, nor Robin Williams Harnish, can be held responsible for property damage, property loss, or personal injury that may occur while attending SPLASH.

MEDIA RELEASE: I grant permission to J. Cornack Therapy Group, and Robin Williams Harnish to use any recordings of my child (photographic, audio, or video) for public relations, and/or teaching purposes.