A+ Socials Student Registration Form

A+ Socials Student Registration Form

Fun, Friendship & Growth in a Safe, Inclusive Space. We’re excited to welcome children ages 3–12 including children with Autism, ADHD, and behavioral challenges to our summer enrichment program — A+ Socials — designed for joyful exploration, learning, and connection.🧠 Backed by ABA principles🎨 Filled with creative, hands-on activities🤝 Focused on nurturing growth and friendships✅ What’s Included:🎨 Art & Craft🎵 Music & Movement🧩 Sensory Bins🔍 Scavenger Hunts📚Storytelling & Classroom Readiness. Time: 9:00 AM – 2:00 PM (Mon–Fri) Location: 33–39 Portmore Drive, Independence City, Portmore. Cost: $17,000 weekly OR $65,000 for the full month. Dates: July 7 – July 31 Call/WhatsApp: (876) 835-8403 Spaces are limited — give your child a summer to remember!
Parent Details:
Parent 1 Full Name*

First NameLast Name
Parent 2 Full Name

First NameLast Name
Address*

Street Address

Town/Community

ParishCountry

Postal / Zip Code
Address

Street Address

Town/Community

ParishCountry

Postal / Zip Code
Primary Phone Number*
Primary Phone Number
Cell Phone Number*
Cell Phone Number
Work Phone Number*
Work Phone Number
E-mail*
example@example.com
E-mail
example@example.com
How did you hear about us?*
Please Specify*
Emergency Contact (If Parents/Guardian cannot be reached)*

First NameLast Name
Relationship to student*
Phone Number*
Please enter a valid phone number.
Student Details:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
School Attending:*
Grade in School*
Does your child have any allergies? YES/NO If yes, please state below.*
Does your child have a medical condition or diagnosis? YES/NO If yes, please state below. (e.g. asthma, epilepsy, autism, adhd)*
Is your child on any medication? If yes, please state below.
Program Selection*
Afternoon Sessions*

ABA TherapyClassroom Transitional SkillsSensory Socials
Payment Options

Bank Transfer or DepositCash
Will you be willing to recommend us?

YesNoMaybe

Please give reference of any two people:

	Full Name	Address	Contact Number
1
2

By checking 'I Agree' below and submitting this form, you, the Parent or Guardian of the above student, agree to release Harmony Therapy and Learning Centre, including instructors, assistants and other paid parties, from liability for any and all injuries which may occur during any learning, therapy or play event or activity. You also agree that you are responsible for health and accident insurance and any medical costs incurred due to injury. You give permission for emergency medical transportation and treatment of your student at your expense should the need arise. You also give your permission for the public display of any studio visual images that your child may appear in.
Should be Empty: