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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