pleAse tell uS aboUt youR family’s Needs! I am interested in the following program(s) for my child. Check all that apply. Day Program with Guided Virtual School Life Skills Program The Mentor Program Core Therapeutic Boxing Program ABA and/or OT services Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY Child's current level of school and where they are enrolled: * Any formal diagnoses they have received: Child's current pediatrician: Your Name * First Name Last Name Your relationship to the child: * Phone * (###) ### #### Email * Is your child a Gardiner Scholarship Recipient? * Yes No Please list Insurance Provider: Please tell us why you are seeking services and how soon you wish to start: For Day Program participants, are you ready to enroll your child today, or be placed on the waiting list if your child's cohort is full? Yes No Not Sure Yet Thank you!
