Parent/Guardian Information *

First Name

Last Name

Phone

(###)

###

####

Child's Name *

First Name

Last Name

How would you describe your child’s typical speech and language? *

Speaks in full sentences clearly

Speaks in short phrases or sentences, but not always clearly

Has difficulty expressing themselves

Uses mostly gestures or limited words

Does your child follow 1-2 step directions (e.g., “Go get your shoes and sit down”)? *

Yes, consistently

Sometimes

Rarely

How well does your child focus during structured group activities (e.g., circle time, storytime)? *

Very well – stays engaged most of the time

Fair – needs occasional redirection

Struggles – requires frequent reminders or breaks

Is your child comfortable participating in a small group setting without a parent present? *

Yes

Sometimes – depends on the environment

No – still adjusting to group settings

Does your child demonstrate any of the following early reading readiness skills? *

Can rhyme or identify rhyming words

Can identify beginning sounds in words

Can clap or count syllables

Recognizes most letters of the alphabet

Knows most letter sounds

Can blend or sound out simple words (e.g., cat, dog)

None of the above yet

Please check each box to acknowledge your understanding of our program policies: *

I understand this is an educational enrichment program, not individualized therapy.

I understand all children must complete Level 1: Pre-Reading Foundations before progressing to other levels, to ensure they have the necessary foundational skills.

I understand that if my child is accepted, I am committing to the full 6-week program.

I understand there are no refunds unless the therapist determines my child is not the right fit for this group.

I understand sessions are not prorated or rescheduled for absences or missed classes unless the therapist needs to cancel.

I agree to support my child in completing the brief homework assigned each week to reinforce learning

I understand this form does not guarantee placement. I will be contacted if my child is a good fit for the group, and an invoice will be sent at that time.