SKILL BUILDERSSKILL BUILDERS
43 Quail Court
Suite 101
Walnut Creek, CA 94596
ph: 925-457-7771
fax: 925-465-4638
bblaney

SKILL BUILDERS
Play and Social Skill Services ____________________________________
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 you child take medication? If yes, explain: _______________________________________________________________
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. Please contact your child’s Case Manager.
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 role models. All classes are based on developmental age and social communication skill level. Therefore assessment and placement is required.
After School Social Skills Class Schedule Fall 2010
(12 week Fall Session - September 13 through December 10, 2010)
Monday Tuesday Wednesday Thursday
3:45 (ages 8 - 10) 3:45 (ages 6 – 7) 3:45 (ages 8 – 10) 3:45 (ages 12 – 14)
5:30 (ages 12 - 14) 5:30 (ages 10 - 11) 5:30 (ages 7 - 8) 5:30 (ages 15 - 18)
Upon receipt of the completed Registration Form and Paid Tuition, your child will be added to the specified program, and pending verification of program suitability. Please review the attached fee schedule to determine tuition as different rates apply to the various programs and services. An Initial consultation and assessment is required for all new students, fees apply. Please make all checks payable to SKILL BUILDERS.
Parent/Guardian Signature:_____________________________________________ Date:_____________________
43 Quail Court, # 101, Walnut Creek, CA 94596 Ph: 925-457-7771 Fax:925-465-4638 Email:bblaney@skillbuildersca.org
SKILL BUILDERS
43 Quail Court
Suite 101
Walnut Creek, CA 94596
ph: 925-457-7771
fax: 925-465-4638
bblaney