Fall 2023 Social Language Groups Registration Form

Social Language Groups Registration

Fall/Winter Friday Groups
Date

MonthDayYear
Date
Please indicate your group time preference below. You will only be placed in ONE group***

Fridays 5:00 PMFridays 6:00 PMEither time works
- We will do our best to accommodate your top choice but group assignments are dependent on age, and social/play and language goals.
- Space is limited! Register early as we will place children on a first come/first serve basis provided there are appropriate peers for their needs. Once your child’s placement is finalized, we will send you payment information (we can NOT bill a credit card on file).
- Groups will run from 9/29 -12/15/23 - 10 sessions in total! (No Groups on 11/10 or 11/24 due to school closures.)
- Cost is $930 total for 10 sessions (45 minutes each)
- Participants should be able to attend to activities and follow directions.
Child's Name:*

First NameLast Name
Gender:*

FM
Child's Birthdate:*

MonthDayYear
Date
Date

MonthDayYear
Date
Age
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Person to contact in an emergency if parent cannot be reached:*
Person(s) other than parent authorized to pick child up from Social Skills Groups:

Social Group Questionnaire
Please list 3 specific social, language and/or play goals you have for your child: *
Please share any supports your child may need to help them participate in groups (e.g., visual schedule, verbal praise): *
Please share some information about your child’s verbal communication (e.g., is conversational, uses single words, uses phrases, scripts): *
Please share some information about your child’s play skills: (e.g., pretends, plays next to others/parallel play, has limited interest in play): *
Please list any challenges your child may have participating in group:*
Please list your child’s interests: *
Has your child participated in a social group in the past?

YesNoOther
Is there anything else you would like to share about your child?

Social Language Groups Registration