Any Dream Will Do 2018-2019

General Information
Student's Name *
Student's Name
Date of Birth *
Date of Birth
Address *
Address
Emergency Contact Information
Please include name, relation, and phone number.
Emergency Medical Information
Health History
Behavior
The George Center serves children with many different needs. To create the best environment for all our students, we need to know a little about your child’s behavior needs.
Personal Needs
If yes, please explain.
Allergies
Please list all known allergies and the management of the reaction.
Therapeutic Goals
The George Center seeks to make art and music accessible to children with special needs. We want to tailor this experience to the needs of your child. Please share two things that you would like us to work on during the group. They can include social, fine or gross motor, behavior, and/or speech goals.
Signature
I have read and understand that the balance of $150 is due as a deposit to reserve a space for my child in class. *
I have read and understand that the remaining balance is due in two $600 installments. The first being due by September 11th, the second is due by December 11th. *
I have read and understand the cancellation policy for this event. *
I intend to use 3rd party funding. *
Today's Date: *
Today's Date: