EXTRA CURRICULAR ACTIVITIES
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Your Child's Name
Child's Date of Birth
Child's Diagnosis (if applicable)
If applicable, please list any dietary restrictions or food allergies your child may have
Please tick the relevant boxes that apply to your child
Able to communicate using 2-3 word phrases or simple sentences
Able to follow simple verbal instructions
Able to play alongside peers
None of the above
What excites your child?
How do you hear about this program?
Newspaper & Magazine
Friend & Family
Word of Mouth
*if other, please specify
Please provide us with any other information that you would like us to know about your child.