Early Language Through Music Group Registration
Fill out the form carefully for registration. The group will take place on Fridays from 9:30-10:15 AM on September 11th, 18th, 25th, and October 2nd and 9th. The fee for the 5-week session is $150. Our office will call to take your payment; unfortunately, we will not be able to do make-up weeks or pro-rated fees.
Caregiver's Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Female
Male
Prefer not to choose
Email
*
example@example.com
Mobile Number
*
Please enter a valid phone number. Speech therapist will call to confirm enrollment.
Format: (000) 000-0000.
My child:
*
Rows
Always
Sometimes
Never
Reacts to sounds
Turns to their name
Looks between an object and an adult
Makes vowel sounds
Makes consonant sounds
Follows a simple command (no, come)
Uses signs or gestures (pointing)
Copies actions
Copies words
Finds a named object
What I love about my child is that they
blanks
*
.
My biggest concern about my child is that
blanks
*
.
I know my child needs something when
*
My child's favorite song is...
*
Where did you hear about this group?
*
Our website
Social media
Friend/family member
Through the outpatient clinic
Other
Additional Comments (please include relevant medical info if applicable):
Submit
Should be Empty: