Every Mile Builds Social Confidence.BRAIN POWER RUN CLUB Name of Client * First Name Last Name Client's Date of Birth MM DD YYYY 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 Please specify: Language(s) Please list all of the language(s) spoken by child or language(s) used with child. Option 1 Option 2 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.
