Confident Solutions, LLC

Holiday Session of Social Skills Classes

I am signing up for: Parent and Child ___________ Parent, Child, & Sibling______________

Today’s Date: ______________________________

Child’s Name: _______________________________ Date of Birth:____________________________

Gender:____________________________________

School: ____________________________________ Grade:_________________________________

Siblings Names & Ages: ___________________________________________________________________

Parent:____________________________________ Relationship to Child:______________________

Address:___________________________________ Cell Phone:______________________________

Email:________________________________________________________________________________

___Guarantor ___Custodial Parent ___Non-Custodial Parent _____ Legal Guardian

Parent:____________________________________ Relationship to Child:______________________

Address:___________________________________ Cell Phone:______________________________

Email:________________________________________________________________________________

___Guarantor ___Custodial Parent ___Non-Custodial Parent _____ Legal Guardian

Child lives with: ________________________________________________________________________Other family members (list ages)

Primary language spoken in home:_________________________________________________________

Diagnosis:_____________________________________________________________________________

Brief Description of child’s past and present services (if any):

_____________________________________________________________________________________

____________________________________________________________________________________

Brief description of current skills:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Is your child able to remain in a group setting without elopement or aggressive behaviors?

___yes ____no

Cancellation Policy: Due to prior preparation and maintaining a small class size to better serve our families, payment in full is due upon registration for the class. If Confident Solutions cancels any sessions due to inclement weather, a make-up session will be offered.