One Time Registration Form

Innovative Sensory Center
2100 Middle Country Road
Centereach NY, 11720
1-844-495-2594
Registration Form

All future participants must fill out this form once prior to filling out the scheduling form and it will be kept on file.
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
MEDICAL INFORMATION

If your child has any medical, physical or developmental concerns please explain them below. If you feel your child may need additional support such as parental involvement due to concerns listed above please note, we offer an intensive needs session, which allows you to accompany your child in the room.
Medical Concerns
Describe any and all important information that pertains to your child as described above.
Should be Empty:

Registration Form