Application

Sean's Sensory Corner
Application Form

Please fill out and send to us to reserve a spot for your family. A donation will be due at the first meeting. You must be at every meeting and complete all assignments.

First Name:
Last Name:
Additional Family Members
Address Street
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Child's name, age, diagnosis and any information you would like to share.	Enter comments here!

Date of Group that you are applying for:
Feb. 16, 2012 - March 8, 2012
6:00 PM - 8:00 PM
Silver Springs Elks Lodge in Belleview
7655 SE County Hwy 25
Belleview, FL 34420

Since this is a small group for each session, we are limiting our groups to 5 couples or families. This makes for a personal and intimate setting. It is also less stressful on the children.

I agree to make all required meetings and complete all assignments given. I will consider the rights of other parents and their children. I will be watchful over my child.

A donation of $40.00 is requested for materials and to keep the program going. Due at the first meeting. A receipt for donation will be issued.

You will be receiving all forms, booklets and information needed at the first class. Dates and location will be e-mailed to you.

We are looking forward to working with your family.

Peace of Mind for Parents