Steady Steps Enrichment
Registration Form
Name of child
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Caregiver
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
What services are you seeking?
Assessment for my child
Workshops
Coaching
Online Consultation
Do you have additional support ?
Occupational Therapy
Speech Therapy
Psychologist
Medical Doctor
Others
My child attends
Mainstream School
Special Education School
Home School
Enrichment Centre
Others
I am concern about his/her
Challenging behaviours
Social Communication / Relational Skills
Emotional outburst
Self worth / Self esteem
Reading / Writing / Comprehension
Memory / Planning / Thinking skills
Others
How did you hear about our services?
Internet
Through a friend
Through an agency
From the Centre / School
Others
Do you have a preferred time slot?
Weekdays morning
Weekday afternoon
Saturday
Intensive 5 days holiday support
Submit
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