WE ROCK THE SPECTRUM KIDS GYM - DOWNEY SERVICE COORDINATOR REFERRAL FORM

WE ROCK THE SPECTRUM KIDS GYM - DOWNEY SERVICE COORDINATOR REFERRAL FORM

This form is intended for Service Coordinators, Regional Centers, and Providers referring families to We Rock the Spectrum Kid's Gym Downey. Please complete the following referral intake form for We Rock the Spectrum Kids Gym - Downey. A waiver must be completed prior to membership starting. PLEASE MAKE SURE THAT AFTER SUMBITTING THIS FORM YOU EMAIL OR UPLOAD A COPY OF THE FACE SHEET AND WHEN POS HAS BEEN SIGNED AND APPROVED THAT WE ALSO RECIEVE A COPY, THANK YOU.
We Rock the Spectrum Kid's Gym - Downey 12212 Paramount Blvd., Downey, CA 90242 Phone: (562) 622-7272 Email: info@werockthespectrumdowney.com
All information provided on this form is considered confidential and intended solely for coordination of services between the referring provider and We Rock the Spectrum Kids Gym Downey. Please remind families that a WAIVER must be completed prior to the membership start date. Follow @wrtsdowney on Instagram or call the gym for updated OPEN PLAY hours and announcements.
Membership Information
Membership Duration
Membership Duration - Other (please specify)
Membership Start Date

MonthDayYear
Membership Start Date Policy: This Intake Form request date on or before the 15th of the month may begin during that same month. Membership Intake Form date after the 15th of the month will begin on the 1st of the following month.
Please have the parent/caregiver begin services on the membership start date/month indicated on this form.

This completed form, together with the approved Purchase of Service (POS), serves as confirmation of the membership start date. A separate start date confirmation will not be sent.
Child's UCI #
Child's name

First NameLast Name
Child's DOB

MonthDayYear
Parent/Guardian Name

First NameLast Name
Parent's Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Primary Email Address
example@example.com
Parent's Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Service Coordinator

First NameLast Name
Service Coordinator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Service Coordinator Email Address
example@example.com
Upload Facesheet

*FACESHEET IS REQUIRED PLEASE UPLOAD*
Cancelof
Upload POS

*if there is a POS please upload here, if not ready yet please make sure to send as soon as it is signed and approved to info@werockthespectrumdowney.com
Cancelof
Additional Details or Comments
WAIVER

PLEASE MAKE SURE PARENT COMPLETES WAIVER PRIOR TO COMING IN TO AVOID ANY CHECK-IN DELAYS.
TERMS AND CONDITIONS OF MONTHLY MEMBERSHIP: A copy of APPROVED POS with signatures needs to be sent to WRTS Downey. Membership is Non-Transferable, Non-Refundable, this membership will ONLY be used for child receiving Regional Services. Monthly Memberships are only to be used for OPEN PLAY. Monthly Membership does not include classes, special events or Camps. Guardian/Caregiver is responsible to call and or follow our social media @wrtsdowney for our OPEN PLAY hours as they do vary especially on the weekends. Adults must always be present and not leave child unattended. Adults are required to remove their shoes and wear grip clean socks at all times while inside the facility. EFFECTIVE JANUARY 1ST, 2025 THERE WILL BE A $35 ONE-TIME REGISTRATION FEE (Non-Refundable) INCLUDED ON INVOICE, PLEASE MAKE SURE THIS FEE IS INCLUDED ON POS AUTHORIZATION. Parent(s) /Guardian are responsible to reach out to WRTS for Status on Membership. ONCE INVOICE HAS BEEN ISSUED AND POS APPROVED, INVOICE IS TO BE PAID IN FULL. NO REFUNDS! Waiver: https://waiver.roller.app/WeRockTheSpectrumDowney
Should be Empty: