NoteAble 2019-2020

General Information
Student's Name *
Student's Name
Date of Birth *
Date of Birth
Address *
Primary Contact Name *
Primary Contact Name
Primary Contact Number *
Primary Contact Number
Emergency Contact Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Number *
Emergency Contact Number
Please include name, relation, and phone number.
Emergency Medical Information
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 day of class.
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.
If yes, please explain.
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.
I have read and understand that the balance of $100 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 $370 installments. The first being due by September 6th, and the second by December 13th, 2018. *
I have read and understand the cancellation policy for this event. *
I intend to bill a third party for these services. *
Today's Date *
Today's Date