COMMUNICATION PARTNERS IN PLAY: Registration form

Childs Name:	Click or tap here to enter text.	Birthdate:	Click or tap here to enter text.
Parents:	Click or tap here to enter text.	School	Click or tap here to enter text.
Address:	Click or tap here to enter text.	Home Phone:	Click or tap here to enter text.
City:	Click or tap here to enter text.	Cell Phone:	Click or tap here to enter text.
Postal Code:	Click or tap here to enter text.
Email:	Click or tap here to enter text.
Emergency Contact:	Click or tap here to enter text.

Allergies:	Click or tap here to enter text.
Medical issues or Diagnosis:	Click or tap here to enter text.
Program:	Explore for ages 2 years 6 months to 3 years ☐ Express for ages 3-5 years with documented language delay ☐
Class Day:	Tuesdays ☐ Wednesdays ☐ or Saturday ☐ We offer classes on these days – please indicate your preference
Time: Please Check one	9:30 ☐ 1:30 ☐ 4:30 ☐ We offer these times – please indicate Saturday 9:30 ☐ and 12:00 ☐ your preference
Payment	$475.00 by cheque or Etransfer. ($52.75/session) Start dates to be determined based on interest – November, January and March
Deadline	Registrations open until class is full - Maximum 6 /minimum 4

You will be contacted by phone to confirm your registration and arrange for payment. Your spot is not guaranteed until payment is received. Our cancellation policy is as follows: 14-7 days prior to the first session – 50% refund – Less than 7 days prior – 0% refund. Please mail, email, fax or drop off your completed form to:	Mail to: Communication Options Inc - P.O. Box 20003 Red Deer AB T4N 6X5

Drop off to: #1 5108- 52 Street – Red Deer Alberta, T4N 6Y4

Email to: info@communicationoptionsinc.ca

Fax: 403-348-8415

Phone: 403-343-0977 if you need further information

Invoices provided to families by session for Insurance/Extended Health Benefits

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Signature of Parent/Guardian Date