Social Bugs
Registration
Dates of Program: Mondays, February 3 through March 24, 2014
Caregiver Meeting: Monday, January 27, 2014 6:30-7:30pm
Location: Reynoldsburg United Methodist Church
Cost: $275 per child
CHILD AND FAMILY INFORMATION
Child’s Name:
Age:
Date of Birth:
Caregiver Name(s):
Address:
Home #:
Cell #:
Payment Source: Private Pay*
Allergies/Medical Conditions:
County**
Email:
Other:
Are siblings attending? Yes/No (Prior permission required)***
Names and ages:
I have read and agree to abide by the sibling policy:
Signature:
Date:
WHICH GROUP WILL YOU BE ATTENDING?
Toddler 1
Ages 15-24 mos.
4:30-5:00pm
Toddler 2
Ages 25-36 mos.
5:15-5:45pm
Pre-K
Ages 3-5 years
6:00-6:30pm
School Age
Ages 5-8 years
6:45-7:15pm
WHAT DO YOU HOPE TO GAIN FROM THIS GROUP?
*If paying privately, full payment of $275 must be received with this registration to reserve your spot.
**If using county funding, prior authorization must be received prior to the start of group.
*** Three siblings per class may be permitted if able to follow our sibling policy. Please request a copy of this
policy at the time of registration.
Please send payments and registration to:
Cornerstone Speech Therapy
P.O. Box 16092 Columbus, Ohio 43216.
Checks can be made out to “Cornerstone Speech Therapy”.
Contact Amanda Unterbrink at (614) 813-5518 for questions about payment or registration.
Thanks!!!
www.wejoysing.com
P.O. Box 843
Grove City, OH 43123
(614) 868-0107
www.cornerstonespeechtherapy.com
7540 Sawmill Pkwy Suite A-2
Powell, OH 43065
(614) 973-9755