Distance Training Program
Registration Form

Thank you for registering for the Growing Minds Distance Training 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)
Child’s Full Name:
Nickname:
Date of Birth:   Gender:   Female     Male
Diagnosis:
Language spoken at home:
Child’s Height:   Child’s Weight: