FUNDAY GROUP | Center for LifeSkills

This group is designed to help 8-11 year olds manage their

social skills. We will learn how to introduce ourselves,

participate appropriately in conversation, and ask questions of

others. We will play games and eat a snack, all while getting

to know each other and make friends.

Funday Group Registration

Permission to attend*
I give permission for my child to participate in Funday Group and all activities associated with it.
- Yes
- No
Mondays or Tuesdays?*
Which day would you like your child to attend the Funday Group?
- Monday
- Tuesday
Today’s date
MM slash DD slash YYYY
Child’s name*
Date of birth*
MM slash DD slash YYYY
Age*
Parents' names*
Address*
City*
ZIP code*
Home phone number*
Email address*
Name by which your child is called*
Who referred you to our practice?
Does your child have a specific medical or educational diagnosis? Please list.
Does your child currently have an IEP?
Does your child attend speech or occupational therapy outside of school?
Allergies
Please tell us a little bit about your child (likes/dislikes, strengths/weaknesses)
Bathroom policy*
I give permission for the therapists or camp volunteers to accompany my child to the bathroom, if necessary.
- Yes
- No
Media release*
I give permission for my child to participate in photos and videos taken during camp for media purposes for The Center for LifeSkills/Stefanie Peck. My child’s first name, photo and/or videos may be used and seen in printed marketing materials, website content, and/or our Facebook business page. Media will not be shared with any third parties, or appear on any personal Facebook pages. This release will remain active until I or my child's guardian notifies The Center for LifeSkills/Stefanie Peck.
- Yes
- No
Monday Funday costs $400 per child for the 10-week session. Once registration is submitted you will be taken to the payment page. If you wish to pay by check, please call the office at 440-498-1100. Thank you!
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