Parent Name *

First Name

Last Name

Phone *

(###)

###

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Child Name *

First Name

Last Name

Group Frequency *

Please check all your frequency preferences for a 1-hour social group this summer:

1 group/week x 4 weeks (4 sessions)

2 groups/week x 4 weeks (8 sessions)

1 group/week x 8 weeks (8 sessions)

2 groups/week x 8 weeks (16 sessions)

Meeting Days *

Please check all days you are available for a 1-hour social group this summer:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Meeting Times *

Please check all time-frames you are available for a 1-hour social group this summer:

Mornings (9am-12pm)

Afternoons (12pm-3pm)

Evenings (3pm-6pm)