A.B.C. Play Registration

A.B.C Play! Registration Form
Sing Explore Create, LLC and Leading Therapy Home are teaming up to provide a unique supportive play opportunity to children 2.9-5! Facilitated by a board-certified music therapist (from Sing Explore Create’s team), as well as a speech language pathologist and/or occupational therapist (from Leading Therapy Home’s team), the group will be a fun and supportive environment that focuses on healthy child development and most importantly time to play and make new friends!
I am registering for... *
Great! When would you like to join us?
Student's Name *

First Name Last Name
Student's Date of Birth *

Month Day Year
Date
Parent/Guardian's Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (to be contacted on day of class) *
Please enter a valid phone number.
Secondary Phone Number *
Please enter a valid phone number.
Primary Language Spoken at Home *
A.B.C. Play is an integrated program that will benefit all children, including those who in need of support in any developmental areas. As with any program held at SEC, support staff (such as ABA therapists) are welcome to assist any child who needs 1:1 support to attend and participate in activities.

My child will not need additional support to sit and attend with the group My child will need additional support to participate in the group and an ABA therapist or other support person will accompany them.
Tell us about your child! We strive to create an environment in which all students can have fun, be comfortable playing during both structured and unstructured play time, and have a successful group experience. Please share anything you would like us to know about your child (personality, learning style, favorite activities, etc.). If you would like to discuss further, please don't hesitate to contact us directly via phone or email. *
I am a Leading Therapy Home client and am interested in discussing the option of using my insurance for the group.

Emergency Information

We collect medical information for all in-person and virtual services. The information provided would be used should we need to contact emergency services during your time with us.
Please list any allergies. Write "N/A" if none. *
Do you have an epi-pen? *

Yes No
Emergency Contact Name *

First Name Last Name
Emergency Contact Relation to Student *
Emergency Contact Phone *
Please enter a valid phone number.
Medical Attention

In the event of an emergency requiring medical attention, I understand that Sing Explore Create, LLC will make every effort to contact and notify the listed parent/guardian and emergency contact listed above. However, if neither can be reached Sing Explore Create, LLC reserves the right to call emergency personnel to transport the student/client to the nearest medical facility to secure necessary medical treatment. This applies to sessions at our center, at-home visits, and online sessions.
*

I have read and agree to the above statement regarding medical attention.
Pick-Up Policy: For students under age 18, we reserve the right to ask for picture identification from anyone picking up students from Sing Explore Create, LLC studios. Only those who have been given written permission from the students' parent/guardian will be allowed to pick up. Please list the names of those who may be picking up the student below. In the event that a student must be picked up by someone not listed below, hand-written notification and permission from the parent/guardian must be given to the teacher prior to the student being dismissed. *

A.B.C Play! Registration Form

Emergency Information

Media Permissions