Color Outside the Lines Kidz Club Waitlist Form
Join our waitlist for a spot at the Kidz Club! Please complete the form below to express your interest.
Welcome to the Kidz Club Waitlist
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Phone Call
Text Message
Email
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Grade Level
Child's Age
*
What type of support does your child currently receive?
Speech Therapy
Occupational Therapy
Physical Therapy
Counseling/Mental Health Support
School-Based Supports (IEP/504)
Other
What program are you interested in?
*
Full-Day Program
After-School Program
School Break/Summer Program
Social Enrichment Activities
Future Programs & Events
Desired Start Date
*
As soon as available
Within 1–3 months
3–6 months
Just exploring options
Other
Does your child have any diagnoses or identified needs you would like us to know about?
What are your goals for your child attending Kidz Club?
Join Waitlist
Should be Empty: