Speak, Learn, and Play

Social Groups Application

Application for Lego Group and Board Games Group

Child's Name*
Date of Birth*
Month
Day
Year
Parents' Names*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email Address*
Child's School*
Child's Current Grade*
Child's Diagnosis (if known)?
Does your child receive any services in or outside of school? If so, which one(s)?
Is your child toilet trained?*
- Yes
- No
If yes, how do they let you know that they need the bathroom?*
Is your child able to feed themselves independently?*
- Yes
- No
What does your child like to play with?*
How does your child manage frustration?*
How does your child manage in small groups?*
What soothes your child?*
Which group(s) are you interested in?*
- Fridays, 3:30 - 4:30pm (Lego Group, Ages 6-8)
- Fridays, 4:45 - 6:15pm (Board Games Group, Ages 9-12)
- Not sure yet
Thank you so much for your interest! We will get back to you as soon as possible.