All About Philly Early Intervention Event
Sign up for our April 23rd, 2024 group connection event by filling out the form below. Do you have questions about early intervention? Are you concerned about your child’s development? Join us as we celebrate Autism Awareness and Autism Acceptance, as well as discuss other special needs. Children ages 0-5 will be able to have developmental screenings done that day and get assistance with referrals for services. Representatives from Kutest Kids Early Intervention will be present to share information on services, including autism evaluations and the new outpatient mental health program.
Your name
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Primary email
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example@example.com
Phone Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List the adult caregiver(s) attending (Date of birth and ethnicity are required for each adult, including yourself, to register for the event)
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First Name
Last Name
Gender
Date of birth
Ethnicity
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List the child(ren) attending (Date of birth and ethnicity are required for each child, to register for the event)
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First Name
Last Name
Gender
Date of birth
Ethnicity
Is this a child that will get a developmental screen done at the event?
List any developmental concerns that you currently have.
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Is English your primary language?
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I authorize the use of the story/photo/video taken of/by me and my child(ren) on April 23rd, 2024 at 7201 Ridge Ave Philadelphia, PA, for the purposes including broadcast, promotions, media, or sales related situations or other uses deemed suitable by Kutest Kids Early Intervention and Parents as Teachers.
I understand Kutest Kids Early Intervention and Parents as Teachers are not responsible for any personal injuries that may occur on April 23rd, 2024 and I will not attempt to hold them liable if any injuries may occur.
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