ABA Clinic Registration

Child's Name*

First Last

Child's Birthday*

Parent's Name*

First Last

Billing Information

Please click "ABA Clinic" and then select the programs you are registering for:*

ABA Clinic

Programs*
DNA-V
Social Thinking
AIM
Zones of Regulation
3 Point scale
Superflex
Cooperative Play
School Readiness
Socially Savvy

Total
$ 0.00 CAD

Option*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Email*

Phone*

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Consent

I permit the photographing/videoing of my child for the purpose of communicating/demonstrating treatment goals or strategies; any electronic copies will not be emailed or stored digitally, and any hard copies will be stored in child’s file*

Yes

No

I provide consent to communicate via email and understand that electronic communication may not be secure. Please use your child’s initials when emailing.*

Yes

No
If you have any questions, please contact shira@kaylaschildrencentre.org

I understand that any information pertaining to my child or my family will be kept confidential. I also understand that if I choose to decline permission now or to revoke my permission at any time in the future, I may do so without any impact on my child’s current or future programming or services. If I wish to revoke my permission in the future, I will submit my request in writing to KCC

Consent to assessment and treatment is hereby provided by:*
First Last

Date*
MM slash DD slash YYYY

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ABA Clinic Registration

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