Baby Floor Time Class Registration

For Ages 12-24 Months

February 5th - March 18th

Wednesdays 9:30am to 10:45am

7 Weeks $158

So that we can aggregate data for use in grant applications to receive funding for our programs and scholarships, we are asking for the following demographical information. Fields marked with a * are required fields.

New and returning families are required to complete the full registraion form each year.

Child Information

Child's Name

*

First Name

Last Name

Child's Date of Birth

*

(mm/dd/yyyy)

Child's Gender

Child's Ethnicity

Child's Disability Status

Primary Caregiver

Primary Caregiver's Name

*

First Name

Last Name

Primary Caregiver’s Relationship to Child

*

Email

*

Verify Email

*

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Primary Caregiver's Birth Date

(mm/dd/yyyy)

Primary Caregiver’s Gender

Primary Caregiver's Ethnicity

Primary Caregiver’s Sexual Orientation

Primary Caregiver's Disability Status

Partner/Secondary Caregiver

Partner/Secondary Caregiver's Name

First Name

Last Name

Partner/Secondary Caregiver’s Relationship to Child

Partner/Secondary Caregiver's Birth Date

(mm/dd/yyyy)

Partner/Secondary Caregiver’s Gender

Partner/Secondary Caregiver’s Ethnicity

Partner/Secondary Caregiver’s Sexual Orientation

Partner/Secondary Caregiver’s Disability Status

Household Information

Household Income

*

Number of People in Household

*

What is the primary language spoken at home?

*

Photo Release

I grant Secure Beginnings, its representatives and employees the right to take photographs and video of me and my child. I authorize Secure Beginnings, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

Will you please support Secure Beginnings in one of the following ways? If so, please select the ways in which you will support us.

Help assemble marketing materials (i.e. stuffing envelopes, folding forms)

Host a Fundraising Event (Annual Tea, Dinner Party)

Join a Committee (Programs, Fundraising, Marketing, Finance)

Business Sponsor or Offer Professional Services

Financial Donation

Other

Not at this time

Please describe how you'd like to support us

Anything else you'd like to share with us

Payment

Are you requesting financial assistance?

*

Please select one of the options below and we will contact you about our sliding scale scholarship program.

Your registration is not complete until you have paid for the class in full or your scholarship request has been confirmed.

*

$158 - Full Class Payment

$0 - I am requesting financial assistance. Please contact me about scholarship program or payment options

$183 - Add $25 to my class payment to help fund scholarships for other families