Student Information 2016-17

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Student Name*

First Name Middle Name Last Name

Date*

Month Day Year

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone*

Area Code Phone Number

Birth Date*

Month Day Year

Mother's Name*

First Name Last Name

Mother's Email*

Mother's Cell Phone*

Area Code Phone Number

Mother's Occupation*

Father's Name*

First Name Last Name

Father's E-mail*

Father's Cell Phone*

Area Code Phone Number

Father's Occupation*

Emergency Contact*

First Name Last Name

Emergency Contact Phone*

Area Code Phone Number

Who referred you?

Does your child receive ACADEMIC TUTORING services? If so, who tutors your child, where and how often?

Update Medical Information

Child's Allergies

Child's Medications

I understand there is no nurse on the premises.*

If my child has a chronic or severe medical problem, I will stay on the premises during treatment.*

Educational Information

Child's School Name*

Child's Grade*

What are your child's school's hours?*

What subjects are difficult for your child?

I understand that I must give at least 24 hours notice if I need to cancel a session. Otherwise, I am obligated to pay for the session.*

I will do my best to NOT schedule doctor, dentist or other appointments during my child's speech language time unless absolutely necessary.*

Financial Policy

I understand payment is due at the end of each session and services can be discontinued due to failure to pay.*

FST creates insurance forms and statements as a courtesy to you. I understand FST does not guarantee reimbursement from insurance.*

I understand I wil be charged for missed appointments*

Signature*

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