Speak to the Beat

08.22.13

SPEAK TO THE BEAT 2013-2014 APPLICATION FORM

Session applying for (please check one):

 3 to 5 years old 5 to 7 years old
Time:
The 3-5 year old group will meet 9:15am to 9:55am.
The 5-7 year old group will meet 10:15am to 10:55am

Application must be received NO LATER than September 1st 2013.

Child's Name (required)

Date of Birth(required)

Parent/Guardian'sName (required)

Adress

City

Zip

Home Phone

Cell Phone

Work Phone

Your Email (required)

Emergency Contact

Medical Diagnosis

Personal Statement

Give us an idea of who your child is. Remember that this program was developed with special needs children in mind. Describe any strengths, weaknesses, special considerations, attention, etc. You know your child best! Together we can make this program enjoyable for each and every child.

What changes or improvements would you like to see in your child as a result of this program?

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Application must be received NO LATER than September 1st 2013.

***All applicants will meet one-on-one with our speech therapist before attending Speak to the Beat***