Social Squad Hosted by Better Together

Social Squad Hosted by Better Together

Please complete this form to register for Social Squad!
Name of Child*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Interested Group Date - Social Club will be held on Fridays from 9am-12pm.*

July 18thAugust 1stAugust 8th
My child currently receives the following services at We are Better Together, School or another location:*

Speech TherapyOccupational TherapyNot Currently Receiving Services
How does your child communicate?*

Non verbalGesturesSingle wordsShort phrasesSentencesEngages in conversationsOther
Diagnoses:*

No diagnosisAutism Spectrum DisorderADHDSpeech/Language DelayDown SyndromeCerebral PalsyCognitive Impairment/Developmental DelayOther
Challenges: Please check the following challenges that describe your child

AnxiousWithdrawnRigidImpulsiveVerbally aggressivePhysically aggressiveDistracted/distracting to othersOppositional
Our current adult to child ratio is approximately 1:5. Will your child need additional support?*

YesNo
I acknowledge that if my child needs additional support, that I will be able to provide it*

YesDoes not apply
What do you hope to gain from the social squad club?*

Conversational skills (greetings, initiates, eye contact, engaging, staying on topic, interrupting)Making friendsPlay skills (turn taking, initiating, following rules, sportsmanship)Practice using or increasing Speech/Language SkillsOther
Other information you would like to share about your child that will help us best accommodate them during Social Squad Club.*
I acknowledge that this is not a free service. I understand that the cost of Social Squad is $60 per class or $200 for all 4 classes and that payment is due at registration. Payment includes social squad classes, the cost of activities, all supplies, and a shirt. No REFUNDS*

I acknowledge
Caregiver/Parent Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Best way to contact you*

EmailPhoneOther
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
How did you find out about our Social Squad? If it was from one of our staff please write in the staff members name. *
Exciting things are coming your way! Keep an eye on your inbox for an email with all the details on what's next in your Social Club journey!
Social Squad Club Registration Fee - There will be a $60 registration fee ($60 per class) or $200 for all 4 classes. This is a nonrefundable fee. *

prevnext( X )
USD$60 per class or $200 for all 4 classes
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Social Squad Hosted by Better Together

Exciting things are coming your way! Keep an eye on your inbox for an email with all the details on what's next in your Social Club journey!