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info@cbc4autism.org
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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?
Public
Private
What scholarship does your child currently have?
McKay scholarship
Gardiner scholarship
None
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