Confident Solutions, LLC

Summer Sessions

Each session is $90.00 and all times are 10:00-12:00. I am signing up for the following summer sessions:

________June 14, 2017 Frank Liske Park

________June 28, 2017 Discovery Place (additional cost- admission $13/child, $17/adult)

________July 12, 2017 Spare Time (additional cost- cost of bowling $8.99 plus shoe rental)

________July 26, 2017 Freedom Park

________August 9, 2017 Imaginon 10-11 Fuel Pizza 11-12 (additional cost- cost of food)

Today’s Date: ______________________________

Child’s Name: _______________________________ Date of Birth:____________________________

**Confident Solutions already has my child’s information on file from a previous registration. By signing, I agree for Confident Solutions to use the information on a past registration form. __________________________________________________________

Gender:____________________________________

School: ____________________________________ Grade:_________________________________

Siblings Names & Ages: ___________________________________________________________________

Parent:____________________________________ Relationship to Child:______________________

Address:___________________________________ Cell Phone:______________________________

Email:________________________________________________________________________________

___Guarantor ___Custodial Parent ___Non-Custodial Parent _____ Legal Guardian

Parent:____________________________________ Relationship to Child:______________________

Address:___________________________________ Cell Phone:______________________________

Email:________________________________________________________________________________

___Guarantor ___Custodial Parent ___Non-Custodial Parent _____ Legal Guardian

Child lives with: ________________________________________________________________________Other family members (list ages)

Primary language spoken in home:_________________________________________________________

Diagnosis:_____________________________________________________________________________

Brief Description of child’s past and present services (if any):

_____________________________________________________________________________________

____________________________________________________________________________________

Brief description of current skills:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Is your child able to remain in a group setting without elopement or aggressive behaviors?

___yes ____no

Cancellation Policy: Due to prior preparation and maintaining a small class size to better serve our families, payment in full is due upon registration for the class. If Confident Solutions cancels any sessions due to inclement weather, a make-up session will be offered.