G.R.O.W. Registration

Participant Name *
Participant Name
Date of Birth *
Date of Birth
For the upcoming school year.
Parent/Guardian 1 *
Parent/Guardian 1
Parent/Guardian 1 *
Parent/Guardian 1
Parent/Guardian 2
Parent/Guardian 2
Parent/Guardian 2
Parent/Guardian 2
Address *
Address
Emergency Contact Information
Name *
Name
Phone *
Phone
Please include name, relation, and phone number.
Doctor's Name *
Doctor's Name
Doctor's Number *
Doctor's Number
Health History
We need the following information in detail to help us serve your child effectively. Any changes to this information should be provided to the Class Instructor upon participant’s arrival the first session.
Please list all known allergies and the management of the reaction. Please type NONE if there are no known allergies.
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
Electronic Signature *
Electronic Signature
Today's Date *
Today's Date