Name of Child * First Name Last Name Child's Age * Primary Contact * First Name Last Name Email * Phone * (###) ### #### Does your child have any of the following diagnoses or learning differences? * Autism ADHD Learning Disability Anxiety Rare Genetic Condition Other If other, please specify: Please list other languages that your child speaks (if any): What are your main social communication goals for your child in this run club? (For example: building confidence in group settings, initiating conversations, taking turns, following group instructions, making friends, etc.) Does your child display any major behavioural issues at home? If yes, please describe. Do you wish to use third party funding? If so, please indicate below: * EXTENDED HEALTH BENEFITS AUTISM FUNDING PRIVATE PAY Other Are you a Speech Meta Client? * Yes No Where did you hear about us? Any comments / questions? Thank you for registering for the Brain Power Run Club. Our team will be in touch with you shortly. Every Mile Builds Social Confidence.BRAIN POWER RUN CLUB
