ABA Clinic Registration – Kayla's Children Centre

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905-738-5542

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ABA Clinic Registrationadmin2023-04-20T18:03:36+00:00

ABA Clinic Registration

Child's Name*
First Last
Child's Birthday*
MM slash DD slash YYYY
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
CAPTCHA

36 Atkinson Avenue, Thornhill, ON L4J 8C9
Charitable Reg. No. 12646 2332 RR0001

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