Toddler Book Club Registration
Fill out the form carefully for registration. Group will take place on Fridays from 10:00-10:45 AM on July 7th, 14th, 28th and August 4th, 11th, 18th.
Caregiver's Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Female
Male
N/A
Email
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
My child can:
*
Always
Sometimes
Never
Find named objects
Follow one step directions
Follow two step directions
Copy actions
Copy sounds
Use one word at a time
Use two words at a time
Use three or more words at a time
Answer yes or no (verbally or by head movement)
Answer wh- questions
What I love about my child is that they
blanks
*
.
My biggest concern about my child is that
blanks
*
.
Where did you hear about this group?
*
Our website
Social media
Friend/family member
Through the outpatient clinic
Other
Additional Comments (please include relevant medical info if applicable):
Submit
Should be Empty: