Download the form here, or fill in your details below and submit on-line
    Sundays in June: 03, 10, 17, 24
    Sundays in July : 01, 08, 15, 22, 29
    English Group Times: 9:00am - 11:00am

    Please select your summer program




    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/Dominant Language Others
    SLP history Current details Previous details

    Administration Procedures:

    A $100 deposit is required to confirm your child's place. Please select your preferred method of payment:


    Your spot is not confirmed until payment is received. Please address all cheques to "Ultra Health Services" and mail to

    Ultra Health Services
    175 avenue Stillview, Suite #230
    Pointe-Claire, Quebec, H9R 4S3

    Do not mail cash.

    Client Agreement

    I agree to pay the full balance or provide pre-dated checks by May 30th, 2018.

    For medical emergency cancellations made before May 15, 2018, I understand that I will be refunded the deposit less a $50 administration fee.

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

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