Today's Date *

MM

DD

YYYY

Student's name *

First Name

Last Name

Student's DOB *

MM

DD

YYYY

Parent name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Choose those that apply *

My child has been here before

My child has received related services (add in comments)

My child has allergies (add in comments)

My child has medical conditions (add in comments)

My child has behavior that can affect participation

None of the above

I understand that *

There is an annual non-refundable $28 registration fee

I can use the Groupon registration discount one time

Consent to videotape/photograph *

I give permission to Sensory Street Pediatric Occupational Therapy P.C to videotape sessions for the promotion of the program. The parent will be notified of the posting. I understand that I may withdraw my permission at any time.

Yes

No