SKILL BUILDERS

Developmental Services for Children

SKILL BUILDERS
39 Quail Court
Suite 200
Walnut Creek, CA 94596

ph: 925-457-7771
fax: 925-465-4638

Registration Form

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Shy ___ Silly ___ Talkative ___ Withdrawn ___ Worried ___ Other(s)__________________________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 14th ___            Spring 2008 groups begin the week of April 7th ____

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

                           (Please number your preferred day and time, 1st, 2nd, and 3rd. 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

 

 

SKILL BUILDERS
39 Quail Court
Suite 200
Walnut Creek, CA 94596

ph: 925-457-7771
fax: 925-465-4638