Enrolment Application

Enrolment Application

* Child's Name

First

Last

* Mother's Name

First

Last

* Father's Name

First

Last

* Date of Birth

* Current School

* Current Grade

* Home Address

Street Address

Address Line 2

City

State / Region / Province

ZIP / Postal Code

Country

* Contact Number - Home

* Contact Number - Work

Contact Number - Mobile

* Postal Address

Street Address

Address Line 2

City

State / Region / Province

ZIP / Postal Code

Country

* Email Address

* Year of Admission

* Child's Requirements

Please give a brief summary of your child's speech and language difficulties

* Current Occupational Therapist

* Current Speech Therapist

* Current Physiotherapist

* Current Audiologist