Cerebral Palsy Ability Center
Registration Form
Summer Camp 2008

Child’s Name:__________________________________ Date of Birth:____________

Gender: M Helping children with motor disorders and disabilities, fighting cerebral palsy with conductive education in washington dc F Helping children with motor disorders and disabilities, fighting cerebral palsy with conductive education in washington dc Current Age: ___ years ___ months

Father’s Name: _____________________________ Work Phone: _______________

Mother’s Name: ____________________________ Work Phone: _______________

Mailing Address: ___________________________ Home Phone: _______________

                                ___________________________ Other Phone: _______________

E-Mail: _________________

1. Child’s diagnosis: ____________________________________________________

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2. Has child participated in Conductive Education? Yes Helping children with motor disorders and disabilities, fighting cerebral palsy with conductive education in washington dc No Helping children with motor disorders and disabilities, fighting cerebral palsy with conductive education in washington dc

If so, when and where? ______________________________________________

___________________________________________________________________

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3. Date of last CE Assessment: _________

4. What additional information should we know about your child? ______________

___________________________________________________________________

___________________________________________________________________

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Parent Signature: __________________________________ Date: _____________

For Office Use Only

Date Received: ________ Deposit Received: _______ Confirmation Sent: _______

Session: __________________________________________________

Conductive Education at Cerebral Palsy Ability Center