Parents' names(s):*FirstLast Child's Name: First Last Child's age:Date of birth: Month Day Year Email Home phone:Cell phone:How did you hear about us? Program of interest (choose one) Day Program (age 19-34) Taglit Summer Program (age 16-22) Summer Inclusion Program (age 5-15) ECE (age 2-5) Evening and/or Weekend Activities (varies) Expected highschool graduation date (if applicable) Month Day Year Classroom experience: Inclusion classroom Self-contained classroom Third Choice Participant InformationDisability/Diagnosis? Individual needs Description of Child (likes, dislikes, goals for joining program, etc.)Are you a DDD Client? No, I will be paying privately Yes Name of Support Coordinator: Support Coordinator #:
