Form
Autism Play & Parent Support Group Registration
Please use this form to register for upcoming Autism Play & Parent Support Groups.
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Child with Autism Name
First Name
Last Name
Child's Age
Other Attending Adult Name (if applicable):
Other Attending Children's Names and Ages (if applicable):
Available Sessions
Sessions are $5 per child. If cost is prohibitive, skip this section. Scholarships may be available.
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Wednesday, September 27, 2024
4-6pm
$
5.00
Quantity
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Wednesday, November 29, 2024
4-6pm
$
5.00
Quantity
1
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Wednesday, January 24, 2024
4-6pm
$
5.00
Quantity
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Wednesday, March 27, 2024
4-6pm
$
5.00
Quantity
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9
10
Wednesday, May 22, 2024
4-6pm
$
5.00
Quantity
1
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5
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10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
If cost is prohibitive, please indicate sessions you wish to attend and number of people attending. Our team will reach out to you to confirm that scholarships are available.
Are you interested in learning more about our Autism Counseling & Support Services program?
*
Yes, please email me
Yes, please call me
No, already a client
Not at this time
Are there any accommodations you're requesting which will allow you and your family to fully participate?
Submit
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