Summer Group Intervention Registration Form

ANNOUNCING OUR SPECIALIZED SUMMER GROUP PROGRAMS!
2 Intensive Therapeutic Group Programs!
Spots are limited for both programs – early registration is highly recommended!

Launch to Literacy
For children in PK and Kindergarten
Targeted reading intervention and writing skill development.
🗓️ Weeks of June 9, 16, 23 and July 7
⏰ Sessions: 9:00–11:15 AM
💲 Cost: $375
🧑‍🏫 Led by a licensed Speech and Language Pathologist trained in OG and other reading intervention approaches
🥪 Please bring a snack

PK/Kindergarten Readiness (READY! SET! PREP!)
For children entering PK and Kindergarten
Builds key skills for school success in the areas of fine motor, executive function, handwriting, social skills, and attention
🗓️ Weeks of June 9, 16, 23 and July 7
⏰ Sessions: 11:15 AM–1:30 PM
💲 Cost: $375
🧑‍🏫 Led by a licensed Occupational Therapist
🥗 Please bring a lunch

📧 Contact: scheduler@therapywest2.com
📝 Additional information & registration form below!
Student Information
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Please indicate any diagnosis or difficulties we should be aware of
Second Child's Name

First NameLast Name
Second Child's Date of Birth

MonthDayYear
Date
Second Child's Age
Second Child - Please indicate any diagnosis or difficulties we should be aware of
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
Payment & Confirmation
PAYMENT OPTIONS

Parents have 2 payment options:

Option 1: Make full payment now

Option 2: Pay 50% now & the remaining 50% by June 1. For this option, please put PayByJune1 in the coupon field.

Registration is not confirmed until payment is received. A confirmation email will be sent upon receipt of the registration form and payment. If a participant cancels, the fee is refundable minus a $50 administration fee. If the program is canceled by the organizer, the full amount will be refunded.

My Products

Launch to Literacy - Week of June 9$375.00

9:00-11:15 am

Quantity

Launch to Literacy - Week of June 16$375.00

9:00-11:15 am

Quantity

Launch to Literacy - Week of June 23$375.00

9:00-11:15 am

Quantity

Launch to Literacy - Week of July 7$375.00

9:00-11:15 am

Quantity

PK/Kindergarten Prep - Week of Jun 9$375.00

11:15 am - 1:30 pm

Quantity

PK/Kindergarten Prep - Week of June 16$375.00

11:15 am - 1:30 pm

Quantity

PK/Kindergarten Prep - Week of June 23$375.00

11:15 am - 1:30 pm

Quantity

PK/Kindergarten Prep - Week of July 7$375.00

11:15 am - 1:30 pm

Quantity

Enter coupon

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

ANNOUNCING OUR SPECIALIZED SUMMER GROUP PROGRAMS!

Student Information

Parent/Guardian Information

Payment & Confirmation