Buddy System Sign-upAre you a returning family?*select an optionYesYes, child attends weeklyNoChild's name* First Last Age*Parent's Name* First Last Email* Phone*Communication Level*uses full words and sentencesnonverbaladapted communication like signs or picturesMobility Level*completely mobileneeds assistancein a wheel chairIs the child at risk to run/wander from adults?* Yes No SometimesTo help us better meet their needs, what is their Medical Diagnosis?*Which service do you all plan to attend? (choose all that apply)* 10AM 11:30AMWhat are the sensitivities/triggers your child may have-sound, physical touch, pain, etc..?*Is your child toilet trained?*select an optionYes - can go independentlyYes - may need assistanceNo - wears a pull upNo - take them at scheduled timeWhen would you like to be notified if your child is having difficulty adjusting?*select an optionRight AwayAfter 15 minutes of tryingNot until the endOtherIf other, please type in your answer*Does your child have a history of aggression?*select an optionYesNoIf Yes, What are the circumstances surrounding those instances?*Any Special notes or comments that would be helpful?*PhoneThis field is for validation purposes and should be left unchanged.Δ
