SKILL BUILDERS

Play and Social Skill Services ____________________________________

Spring 2010 Group 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 age and developmentally appropriate peers and role models.  Therefore, your flexibility may be required in order to place your child in the most appropriate group.  Please indicate which day of the week and time you prefer.  List your preference by using 1^st, 2^nd and 3^rd followed by the time of day.

          Monday                                     Tuesday                                Wednesday                           Thursday                               Friday

___ 3:45 (age 5 – 7)            ___ 3:45 (age 5 – 7)            ___ 3:45 (age 8 – 11)         ___ 3:45 (age 11 – 14)       ___ 3:45 (age 11 – 14)

___ 5:30 (ages 8- 11)          ___ 5:30 (ages 8- 11)         ___ 5:30 (ages 5- 7)           ___ 5:30 (ages 15- 18)       ___ 5:30 (ages 15- 18)

Upon receipt of the completed Registration Form and Paid Tuition, your child will be added to the specified group.  Group Tuition: $450 for new students or $400 for continuing students.  Please make all checks payable to SKILL BUILDERS.     43 Quail Court, # 204, Walnut Creek, CA 94596 Ph: 925-457-7771 Fax:925-465-4638 Email:bblaney@skillbuildersca.org

Parent/Guardian Signature:_____________________________________________Date:_____________________