Email* Child's Name*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Age*Parents' Names*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneAny allergies or special alerts?What school does your child attend?*What grade is your child currently in?*What is your child's diagnosis (if known)?What therapies does your child currently receive in and out of school?*Please describe your child's communication skills (communicating wants/needs, following directions, etc.):*Please describe your child's social skills (who do they like to play with, how to they manage groups, how do they manage frustration, etc.):*Please describe your child's self-help skills (eating, using the bathroom, etc.)*Please describe your child's fine motor skills (using their hands, putting things together, etc.)*What is your child's board game experience (favorite games, handling winning/losing, attention span)?*What are your goals for your child in this group?*Thank you so much for your interest! We will get back to you as soon as possible.