Comprehensive Program
Registration Form

Thank you for registering for the Growing Minds Comprehensive Program. In order to better serve you we have placed this registration form online. The information requested below is quite extensive. It will help us to create the best program possible for you and your child.
PrintYou may want to print out this form, gather the information, then return later to this page and enter the information. You can also fax this form to us at 1-561-748-6543.

Part 1

Mother’s Name:
Father’s Name:
Mailing Address:
City:
State/Providence:
ZIP / Postal Code:
Country:
Phone:
Fax:
Email Address:
* Required Field
Please enter your full email address
(example: yourname@yourisp.net)
Child lives with: Both parents   Mother    Father
Other: (please explain)
Please indicate your relationship to the child: Mother    Father    Other: (please describe)
Will both parents participate in the 5-day program? Yes     No
Will you be using a translator for the 5-day program? Yes     No
(All session are conducted in English. If English is not the primary language spoken at home, you will need to bring a translator to assist your child while parents are being trained separately. Please call us if you have questions about this.)
Available Dates

Please call for available dates: 1-561-748-9697
Child’s Full Name:
Nickname:
Date of Birth:   Gender:   Female     Male
Diagnosis:
Language spoken at home:
Child’s Height:   Child’s Weight:
Names and ages of child’s siblings:   Age:
  Age:
  Age:
  Age:
  Age:

If children under 16 are accompanying you to Florida, you will need separate child care for them, so that your training with us can be focused on your child with special needs.
Please list the names of other adults who will participate in the 5-day program, and state their relationship to the child (e.g. grandparent, program volunteer, etc.)   Relationship:
  Relationship:
  Relationship:
  Relationship:
  Relationship:
  Relationship:

We can accommodate a maximum of 6 adults (age 16 or older) for the training program.