Hanen – Registration


 

    Download the form here, or fill in your details below and submit on-line.
    Free orientation and pre-program consultation: February 11, 2017 @ 2pm
    Workshop dates – 6 weeks: February 18, 25 March 4, 11, 18, 25 @ 2-4pm


    Please choose your pre-registration option

    Single Parent

    Both Parents


    Family Information:

    Child's full name:
    Date of Birth (YY/MM/DD):
    Home Address: street
    city
    Province
    Postal Code
    Phone numbers: Home Mobile
    Email Address
    Parents/Guardians Mother Father
    Parental Authority
    If not "Both", please give details
    Languages First Others
    SLP history Current details Previous details

    Administration Procedures:

    • Receipts can be issued in the parents’ names, and can be split up to reflect each date of service.
    • Payment can be made by cash, check or e-transfer.
    • Full payment or post-dated checks are required to confirm your spot.

    Please address all checks to: ULTRA-Health Services

    Client Agreement

    I agree to attend the orientation on February 11, 2017.

    I agree to pay the full balance by February 18th, 2017.

    I understand that for any missed sessions during the program, all materials and home activities will be provided to me by email.

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