Clone of Spring 2025 Playgroup Registration Form

Play Date Interest Form

Please fill out our play date interest form to provide us with the information we need to match your child with a peer who is a good fit!
Once a suitable peer is found, our play date coordinator will contact you to set up the registration process.

Play dates are booked in 8 week blocks and are billed hourly at $75.00/hr.

Child Information
Child Name*

First NameLast Name
Gender*
Age*
Date of Birth*

MonthDayYear
Important medical information*
How did you hear about this class? *
Which day/time(s) are you available for playdates (select all that apply)?

Thursday afternoons (12-3pm)Thursday evening (3-6pm)Saturday mornings (10-12pm)Saturday afternoons (12-3pm)
What are some of your child's favourite toys, activities, shows, topics? What do they love to do?
How does your child communicate?

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

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:*
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:
Should be Empty:

Play Date Interest Form