Playgroup Registration Form

Playgroup Registration Form

Please fill the form below to register for our parent participation early social communication play group!
The goal of the Parent and Toddler Playgroup is to empower parents and caregivers by enhancing their current skills and abilities, with additional support to help their child with their communication, social skills and play skills. The playgroup will be structured in a way that allows parents and caregivers to interact with their child, as well as receive individualized support from the group lead, a trained UP Clinician.

Winter Session: January 18 - February 25th, 2025
- Tuesdays, 10:45-11:45
- Saturdays, 10:00-11:00 - (FULL)
- 6 classes
- Cost: $290.00/session
At UP Early Intervention Clinic

3688 Cessna Drive, Richmond, BC

Payment:
25% sibling discount for 2nd child registered
If families have Autism funding available, this can be used to pay for the program.
A reduced rate may be available for those who want to participate but are not able to due to financial constraints; please contact us for availability of supported registration.

Learn more about our programs and offerings: https://www.upearlyintervention.com/

Child Information
Child Name*

First NameLast Name
Gender*
Age*
Date of Birth*

MonthDayYear
Important medical information*
How did you hear about this class? *
Which class(es) would you like to register for?

Winter: Jan 18 - Feb 25, Tuesdays, 10:45-11:45, $290.00Winter: Jan 18 - Feb 25, Saturdays, 10:45-11:45, $290.00 - WAITLIST ONLY

Signature & Payment
Preferred Payment Method

Credit CardPre-authorized DebitAvailable Autism Funding Account
Confidentiality Agreement

At UP Early Intervention Clinic, Inc., we respect and value the confidentiality of all of our clients and their families. We appreciate having parents and caregivers as active parts of the intervention process. We also appreciate being able to share our space with providers and community agencies that are interested in learning about Applied Behavior Analysis, the Early Start Denver Model, and the services we offer. In order to maintain these practices, we require any parent, volunteer or visitor to commit to maintaining strict confidentiality with regards to any observations or information regarding clients during your time at UP Early Intervention Clinic, Inc. This includes but is not limited do clients’ needs, programming or personal information, names, ages, diagnoses, and treatment goal targets, or information regarding UP Early Intervention Clinic, Inc’s business or clinical practices.
I have reviewed UP Early Intervention Clinic, Inc’s confidentiality policy as stated above, and agree to maintain confidentiality of other clients receiving therapy at UP and PAF-N. Initials:*
Today's Date*

MonthDayYear
Date
Signature

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Our staff will be in touch regarding setting up your preferred payment method and processing tuition fees for the class.
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