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(305) 271-8790

Parent 1 Name
First Last
Parent 1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent 1 Email
Parent 2 Name
First Last
Parent 2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent 2 Email
Child's Name
First Last
Child's Age
Please enter a number less than or equal to 15.
What school is your child attending?
What scholarship does your child currently have?
Are you happy with the progress your child is making at school?*
- Yes
- No
Is Your Child Receiving Therapy?

Select YES or NO in any of the Therapies listed below
Aba Therapy
- Yes
- No
Speech Therapy
- Yes
- No
Physical Therapy
- Yes
- No
Occupational Therapy
- Yes
- No
What insurance does your child have?
- Medicaid
- Other-please list below
Other Insurances please list below
Would you like to set up a tour of our school?
- Yes
- No
What is the best time to contact you?
- 8-4 PM
- 4-9 PM
Is your child currently enrolled in a summer camp?
- Yes
- No
Would you like more information about our camps and therapy?
- Yes
- No

Tavernier

Miami