Registration

Information About the Client:

Client's Full Name*:

Group Attending*:
Elementary Group: Monday 3:30 PMPreschool Group: Tuesdays 9:00 AMMiddle School Group: Thursday 5:30 PMHigh School Group: Tuesday 5:30 PMYoung Adult Group: Fridays 3:30 PM

Client's Gender:
FemaleMaleOther

Client's Date of Birth*:

Current Grade:*:
preschoolkindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAdult

Client's School:

List any specific diagnoses for the Client (Please state "None" if no exist)*:

List any relevant medical conditions for the Client (Please state "None" if none exist)*:

What type of special education program does the client attend? (e.g., Mild-Moderate Special Education/RSP, Moderate-Severe Special Education/SDC, General Education with supports, General Education with one-on-one aide, General Education without an IEP) *:

List any behavioral concerns for the Attendee (Please state "None" if none exist)*:

Are you a regional center client? If so, what program are you in?:
SDPTraditionalDoes not apply

Do you plan to pay for this program using Regional Center funds?
YesNoDoes not apply

What is your child's Regional Center UCI number?

List any allergies or dietary restrictions for the Attendee (Please state "None" if no exist)*:

List areas of interest and favorite activities of the Attendee:

Information About the Client's Parent/Guardian:

Name of Client's Parent/Guardian*:

Telephone Numbers for Client's Parent/Guardian*:

Email Address for Client's Parent/Guardian*:

As the Parent/Guardian, what are your goals for your son or daughter while they are participating in social groups?:

How did you hear about us?: