SKILL BUILDERS

Play and Social Skills Services

Program Registration Form

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 & Services___________________________________

Siblings Name, Age, School and Grade_________________________________________________________________

Referred by________________________Pediatrician _____________________________Phone#__________________

Emergency Contact:______________________________Relationship_________________Phone #_________________

Does you child have a disability or diagnosis, explain: ______________________________________________________

Does your child have and IEP? If yes, Briefly explain:________________________________________________________

Does your child have any emotional or behavioral challenges?, If yes, explain:____________________________________

Does you child take medication? If yes, list medication and symptoms:_________________________________________

Does your child have any food allergies or special diet? If yes, explain: _________________________________________

What are some developmental social/communication goals you would like your child to work towards?________________

________________________________________________________________________________________________

What are some of your child’s social/communication and developmental strengths?_______________________________

________________________________________________________________________________________________

Program Information

Continuing Student:  Yes / No (New students must complete program assessment process in addition to registration)

Will services be funded by the Regional Center of the East Bay (RCEB)?  Yes / No   

If Yes, Case Manager Name: _______________________________ Phone #:_______________________

RCEB authorization of services must be received before services commence. 

All programs are designed to meet the developmental needs of the students in the group. We make every effort to match students with a variety of developmentally appropriate peers and or role models.  All classes are based on developmental age, grade and social communication skill level.  Therefore assessment and placement is required.

After School Play and Social Skills Class Schedule 2011-2012

   _______   12- week Winter Session - December 5 through March 9, 2012, Tuition $576 (Registration Deadline 11/4/11)   

  _______   12- week Spring Session - March 19 through June 15, 2012, Tuition $576 (Registration Deadline 2/17/12)

After School Play and Social Skills Class Schedule 2012-2013

  _______   12- week Fall Session - August 20 through November 15, 2012, Tuition $576 (Registration Deadline 6/1/12)

  _______   12- week Winter Session - December 3 through March 8, 2013, Tuition $576 (Registration Deadline 10/5/12)

   _______    12- week Spring Session - March 18 through June 14, 2013, Tuition $576 (Registration Deadline 1/5/13) 

Upon receipt of the completed Registration Form and Paid Tuition, your child will be added to the most suitable and available program.  *An Initial consultation and assessment is required for all new students, fees apply.  I have reviewed the fees and tuition page and determined cost as different rates apply to the various programs and services. Please make all checks payable to SKILL BUILDERS. 

Parent/Guardian Signature:_____________________________________________         Date:_________________

39 Quail Court, # 301, Walnut Creek, CA 94596 Ph: 925-457-7771 Fax:925-465-4638 Email:bblaney@skillbuildersca.org