Registration for Special Autism Program

 

 

Child's info:

Name (Firs, Last)

Address

Age

DOB

Describe level of Autism  -   Fully verbal  Partially Verbal somewhat -to non Verbal 

Non Verbal 

Please describe any medications child is on currently 

Is your child living at home?   Yes  No

If not, describe where 

Is your child adopted?   Yes  No

Comments  

Parents Information:

Marital status:    Married  Divorced  explain other 

Address   City  Zip 

Father's Information

Name  (First Last)  

Email  

Cel  

Mother's  Information

Name  

Email  

Cel  

This program is HEAVILY subsidized to make it affordable for parents.  Sponsors are welcomed.

A $100 deposit is required to reserve a place. The total cost of the program of 1 week is $500. No child is turned down for lack of funds. Please contact us if you need to speak to Rabbi Heber. 516-626-0600.

Credit Card information 

Name on Card  

Address on card if different  

Card Number 

Expiration