Parents' names(s):*FirstLast Child's Name: First Last Child's age:Date of birth: MM DD YYYY 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) MM DD YYYY Classroom experience:Inclusion classroomSelf-contained classroomThird ChoiceParticipant InformationDisability/Diagnosis?Individual needsDescription of Child (likes, dislikes, goals for joining program, etc.)Are you a DDD Client?No, I will be paying privatelyYesName of Support Coordinator:Support Coordinator #:
