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* 1. Your first and last name and relation to child:

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* 2. Your cell phone number and email address for registration and payment link:

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* 3. Child’s first and last name:

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* 4. Child’s age and date of birth:

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* 5. What is the primary concern about this child’s speech, language, play, or social skills? Why do you think this group will benefit your family?

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* 6. This class is run by a Pediatric Speech Language Pathologist. What specifically would you like us to focus on while teaching your child in the areas of Speech (Articulation), Language (Receptive and Expressive), Play, or Social Skills? e.g.: clarity of k and g sounds, increasing vocabulary, using two words together, turn taking, following directions, playing appropriately with toys, etc.

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* 7. What experience has this child had with interacting with other children their age?

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* 8. What else would you like us to know about this child?

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* 9. Are their any known diagnoses or behavioral concerns? If so, what are they and how are they best addressed?

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* 10. Do you consent to the following:
1. Observation of your child by the other caregivers in the group and our University of Jacksonville Graduate Student.
2. To remain on site for the duration of the class.
3. To all photography and videography of you and your child and agree to allow it to be used for Social Media and any promotional purposes during and after the group.
4. To hold harmless Look Whoo’s Talking, LLC and it’s affiliates for any use of photos or videos and any harm or injury related to this class on or off-site of the center/office/site. 5. Do you agree to pay the total amount due $444 regular rate or $360 Summer Special Rate if paid by the due date (two weeks prior to start of classes)?

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