Confident Solutions LLC Today’s Date: ______________________________

Child’s Name: _______________________________ Date of Birth:____________________________

Gender:____________________________________

School: ____________________________________ Grade:_________________________________

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. Refunds will be issued prior to 30 days before the first class session. If Confident Solutions cancels any sessions due to inclement weather, a make-up session will be offered.