Social Skills Registration Form Social Skills Class Social skills classes will run Fall 2014. The registration fee must be paid in order to secure your child's place. Sessions must be paid before the first class. No refunds will be given for missed classes. This allows the cost to remain low and keep small teacher-to-client ratios. Groups will be 3-5 individuals. A $25 registration fee is due upon registration to secure the individual's space. Additional session days/times may be added if needed. First come, first serve for day and time preference if additional sessions are added. A minimum of 3 individuals are required for the class to make. Any individuals who have not attended intervention before at Jackson Autism Center must schedule a 15 minute session prior to the classes beginning to help determine the best placement for the individual. You will be contacted to set this up and it is included in the cost of the class. *Classes will run Sept. 15-19 through Nov. 17-21. Parent/Guardian* First Last Individual's Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone*Age*Diagnosis(es)Strengths:*Weaknesses:Likes:*Dislikes:*Dietary restrictions or allergies:Other Important Information Specific to Your Child: Select shift and mark the items below your child can do:*Read simple sentences.Identify name.Write name.Write simple sentences.Play simple board games.Work independently for approx. 10 minutes.Take turns with peers.Wait for a turn to talk.Listen attentively.Sit for 10+ minutesAttend to peersIdentify and understand simple emotions (happy, sad. mad, scared)NARegistration Fee* Price: $25.00 By registering, you are agreeing to pay for the registration fee ($25) now and the entire amount of the social skills class ($400) by the first day of classes. Classes meet weekly for 1 hour 10 times.Class Choice* 5-7 years 8-10 years Middle School Age High School *If there are enough requests for an adult class, one may be added.
