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
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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