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 This page uses 128 bit SSL encryption to keep your data secure.
