Playgroup Registration Form

Level UP Social Skills Group Registration Form

Please fill the form below to register for our Level UP Social Skilsl Group Program!
A group based, social-emotional skill development program for kids aged 5-8 years. Classes will follow a structured social learning curriculum using evidence-based teaching strategies and strong clinical oversight to help kids with social communication difficulties find confidence in social situations. Topics are varied each session to provide a learning opportunities across in a variety of social skills learning through the year.

Groups will cover topics such as: play, communication, social reciprocity, social initiation, perspective taking, conversation, friendship, executive functioning and emotion regulation skills.

Our groups are led by an experienced behaviour interventionist trained in our Level UP program, with supervision, training and oversight of a Board Certified Behaviour Analyst and Clinical Director. The program lessons have all been developed by Maria Sample, MA, BCBA, using evidence based social teaching strategies.

Spring Session: April 1st - June 6th (8 classes)
- Saturdays - 11:30-1:00
- 8 weeks
- Classes occur on April 5th, 12th, 26th, May 3rd, 10th, 31st, June 7th and June 14th.
  NO CLASSES on April 19th (Easter weekend), and May 17th (Victoria day weekend)
- Cost: $880.00 per session (8 classes at $110.00/class)
REGISTRATION IS FULL; please complete the form below to be added to the waitlist

Payment:
25% sibling discount for 2nd child registered
If families have Autism funding available, this can be used to pay for the program. A completed RTP form must be received before the first class.
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? *

Primary Contact Information
Parent/Guardian 1 - Name

First NameLast Name
Mobile Phone
Home Phone
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent-Guardian 2 - Name

First NameLast Name
Mobile Phone
Home Phone
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Payment Information
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:*
Thank you for completing this registration form! Our front desk will be in touch with you within 2 business days to confirm your registration and payment details. Please note, if your payment details (confirmed payment method or completed request to pay form) are not received by us within 1 week of our request, your registration will be put on hold and the next family looking for a spot will be given priority to register. Please initial that you understand this policy: *
Thank you for your interest in our programs!
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Level UP Social Skills Group Registration Form