Summer Group Sign Up - Community Speech Services

Text

Please enable JavaScript in your browser to complete this form.

Child's Name *

First

Last

Group(s) you would like to enroll in: *

T-Shirt Size *

Child's Age *

Parent/Guardian Name *

First

Last

Phone Number *

Email *

Your payment will be made by: *

Day of the Week Preferences (select all days you are available) *

Time of the Day Preferences (select all times you are available) *

List 3 main concerns you have for your child: *

While we have many ideas for summer groups, we want to incorporate your ideas as well.

I want my child to be able to: *

Food Related – My child is allergic to: *

We would like to incorporate the social aspects of meals/snacks into the group. Thank you for your assistance in helping us plan ahead!

Items that my child always eats or drinks are: *

We would like to incorporate the social aspects of meals/snacks into the group. Thank you for your assistance in helping us plan ahead!

My child never eats or drinks: *

We would like to incorporate the social aspects of meals/snacks into the group. Thank you for your assistance in helping us plan ahead!

Connect with us

Don’t worry! We won’t share your info.

4700 Massillon Rd

Green, OH 44232

| Developed & Designed by The Dev Q