Fall Preschool Prep Registration Form
Welcome to our 12-Week Fall Preschool Prep Program! This small-group program is designed to help children build the foundational skills needed for a successful transition into preschool, including following routines and directions, social interaction, cooperative play, attention, fine-motor and pre-writing skills, gross-motor coordination, and independence.The program runs September 14–December 11, 2026, on Mondays, Wednesdays, and Fridays. Families may choose the Half-Day Program from 8:30 AM–12:00 PM or the Drop-In Program from 10:00 AM–12:00 PM. Please complete the form below to register your child and select your preferred program option. Space is limited!
Child's Full Name
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First Name
Last Name
Child's Date of Birth
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Month
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Day
Year
Date
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Does your child have any allergies?
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No known allergies
Food allergies
Medication allergies
Environmental allergies
Other
Please list and describe any allergies your child has.
Is there anything else we should know about your child?
Program Choice
M,W,F Half Day Program 8:30am-12:00pm $250 week - Free week (must commit to whole program)
Monday Drop in $50 10:00am-12:00pm
Wednesday Drop in $50 10:00am-12:00pm
Friday Drop in $50 10:00am-12:00pm
Monday Half Day Program 8:30am-12:00pm $84
Wednesday Half Day Program 8:30am-12:00pm $84
Friday Half Day Program 8:30am-12:00pm $84
Notes for scheduling
Pay Via:
Please Select
Credit Card ( fees apply)
Venmo (5% discount)
I understand the door of the sensory gym has a lock for the safety of my child. We do not wantthe children running on equipment when we are with another child as well as strangers enteringthe building. I understand that the code to the door will not be shared with parents.SAFETY AND PHYSICAL CONTACTPediatric Therapy of South Jersey and all Therapists assure to the best of their ability that your child is kept safe in the office. If a child should engage in behaviors dangerous to her/himself or therapists during a session and cannot stop these behaviors independently, Therapist can cancel the sessions at any time with payment still provided. In addition, in the course of assessment or treatment, young children sometimes seek physical contact with the therapist in the form of hugs.Pediatric Therapy of South Jersey assures that any physical contact is positive and safe due to sensory seeking behaviors. Parents are encouraged to contact the Therapist whenever they havequestions about their child’s treatment.CONSENT FOR PARTICIPATION WITH THERAPEUTIC EQUIPMENTIntervention programs usually involve the use of specialized equipment such as various swings,bolsters, inflated therapy balls, climbing structures, tactile media (such as soap foam, Play-Doh,and lotion), and a variety of other activities that involve fine, gross, and oral motor coordination.Therapy activities often involve encouraging the child to try new things in order to foster increasedskills and abilities. While staff make great efforts to ensure each child's safety, the nature of thetherapeutic intervention includes the risk of injury in falling and bumping into otherpeople/equipment. I am aware of the inherent risk of this type of activity and I give permission for my child to participate in therapy as described. Sign below First last name with Date
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EMERGENCY MEDICAL RELEASEIn the event medical attention is required for your child while on the premises, we need your authorizationto implement treatment. Please read and sign the statement below.I give my permission for Pediatric Therapy of South Jersey to contact emergency personnel in the event of a medical emergency. Sign below First last name with Date
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