Registration Form

Registration Form

Complete this form to register your child for Lil’ Rascals Clubhouse. This information helps us create a supportive and engaging group experience for your child.
Childs Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Grade
Does the child have any allergies?
Does the child have any medical conditions that we should be aware of?
What motivates your child? (e.g., stickers, dinosaurs, movement, music, bubbles, praise, etc.)
How does your child communicate?
Does your child benefit from any of the following:
What social skills would you like your child to work on?
Are there any behaviors we should be aware of?
What situations or triggers may be challenging for your child? (e.g., waiting, loud noises, transitions, losing games, changes in routine, being told "no," etc.)
What strategies help your child regulate or calm down?
What are early signs that your child is becoming overwhelmed?
My child enjoys:
Group themes my child would enjoy:
Is your child toilet trained?
Group Selection
When would like to start?

MonthDayYear
Date
My child works best with:
Lil' Rascals Clubhouse includes children with a variety of strengths, learning styles, and abilities. Are you comfortable with your child participating in a mixed-ability group?
Groups are often formed based on children's age and shared interests. If another child with similar interests is unavailable on your selected date, would you be comfortable with your child participating in a therapist-led themed group instead?
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship
Payment Details
- Session Fee: $65
- Payment can be made via Zelle to:
  
  care@lilrascalstherapy.com
- Please include your child's name and selected group date in the payment memo.
- Payment is due no later than the morning of your child's scheduled group session.
- Your registration is confirmed once payment has been received.
Parent Agreement
Signature
Should be Empty:

Registration Form

Parent/Guardian Information

Payment Details

Parent Agreement