Friendship Club Registration
1.
Child's Name: (First Name, Last Name)
2.
Date of Birth: (mm/dd/yyyy)
3.
Parent's Name: (First Name, Last Name)
4.
Contact Number:
5.
Email Address:
6.
Goals you want your child to learn in a social setting.
7.
Does your child communicate their wants and needs effectively?
Yes
No
8.
Is your child interested in interacting with other children?
Yes
No
9.
Does your child engaged in challenging behavior?
Yes
No
If yes, (please specify)