Date:____/____/______

Family Information

Child's Name________________________________________ Birth Date ____/____/__ Age____ Grade ____ Gender M  F

Parent/Guardian's Names____________________________________________          Home Phone #___________________ 

Address_________________________________________City_______________________________Zip ___________

Work Phone #______________Cellular Phone #_________________Email Address(s)______________________________

School of Attendance__________________________________ Programs and Services______________________________

Siblings Name, Age, School and Grade_____________________________________________________________________

Referred by_____________________________________ Pediatrician____________________________________________

Child Development Information

Early childhood development: Normal ____ Delayed ____ Advanced ____  Comments________________________________

Current Language level:    Age Appropriate ____         Delayed __ # of years    Advanced ____ # of years

Behavior and Demeanor: Aggressive ___ Active ___ Anxious___ Playful ___ Quiet ___ Serious ___

Shy ___ Silly ___ Talkative ___ Withdrawn ___ Worried ___ Other(s)__________________________

Strengths and Weakness: ______________________________________________________________________________

Disabilities or Diagnosis: ______________________________________________________________________________

Individual and group experiences, list name and type: _________________________________________________________

Additional Information, Comments or Concerns: _____________________________________________________________      

Desired Skill Group

Play/Social Skills  ____      Social Communication Skills____     Life Skills/Stress & Coping ____    Org/Time Management ____

Program Schedule

                Winter 2008 groups begin the week of January 14^th ___            Spring 2008 groups begin the week of April 7^th ____

                Summer 2008 groups begin the week of July 10^th ____             Fall 2008 groups begin the week of September 15^th ___

                           (Please number your preferred day and time, 1^st, 2^nd, and 3^rd. We will do are best to accommodate your request)

                  Children are grouped according to skill level, then by age:  ages 4 to 6,  ages 7 to 9 ,  ages 10 to 12,   ages 13 to 15 and  16 & up

Monday                  1:30 to 3:00____ (Pre-K)                   3:30 to 5:00____                 5:30 to 7:00____              

Tuesday                1:30 to 3:00____ (Pre-K)                   3:30 to 5:00____                 5:30 to 7:00____

Wednesday          1:30 to 3:00____ (Pre-K)                   3:30 to 5:00____                 5:30 to 7:00____                                                             

Thursday               1:30 to 3:00____ (Pre-K)                   3:30 to 5:00____                 5:30 to 7:00____

 Registration

In order to determine your child's skill level, needs and program options, a one-time 90-minute child and parent(s) consultation and skill assessment is required. The cost of the consultation and skill assessment is $125, payable on the date of the consultation and prior to program enrollment. Upon receipt of a completed registration form and paid tuition/fees, your child will be added to the specified class list. Please make all checks payable to Skill Builders. A service charge of $25 will be charged for returned checks. 

SKILL BUILDERS

Developmental Services for Children

39 Quail Court, Suite 200 ▲   Walnut Creek, CA 94596  ▲  Call:  925 .  457 .  7771  ▲   Fax:  925 .  465 .  4638

www.skillbuildersca.org