Parent Information Form
Divine Freedom of Feeling Autism Daycare & Learning Center
Thank you for your interest in Divine Freedom of Feeling Autism Daycare & Learning Center. Our center was created from lived experience and a deep desire to support children with autism and their families.We are currently preparing to open and are awaiting final licensing approval from the Alabama Department of Human Resources (DHR). Families who complete this form will be contacted once enrollment officially opens.
Parent / Guardian Information
*
Parent / Guardian First Name
Parent / Guardian Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Preferred Contact Method
*
Phone
Email
Text
Child Information
Child Information
*
Child's First Name
Child's Last Name
Child's Date of Birth
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-
Month
-
Day
Year
Date
Child's Age
*
Does your child currently have an autism diagnosis?
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Yes
Currently being evaluated
No diagnosis yet
Current Support Services
Does your child currently receive any outside therapies or support services? (This helps us better understand the needs of families in our community.)
Check all that apply:
Speech Therapy
Occupational Therapy
Physical Therapy
ABA Therpay
Early Intervention Therapy
None currently
Care Needs
What type of care are you interested in?
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Full-time care
Part-time care
Preferred Start Date
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-
Month
-
Day
Year
Date
Does your child currently attend another daycare or program?
*
Yes
No
Child Support Needs
Does your child benefit from any of the following?
Check all that apply
Communication support
Sensory accomadations
Behavioral support
Feeding support
Potty training support
Structured routines
Child Environment
What type of environment helps you child thrive?
*
Additional Information
Is there anything you would like us to know about your child?
Updates
Would you like to receive updates when enrollment is open?
*
Yes
No
Important Notice
Submitting this form does not gurantee enrollment. Divine Freedom of Feeling Autism Daycare & Learning Center is currently awaiting licensing approval from the Alabama Department of Human Resources (DHR). Families who join our interest list will be contacted when enrollment officially opens.
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