Registration Form

Participant's Name

First Name

Last Name

Parent/Carers Name *

Enter your name

First Name

Last Name

Phone *

Enter your phone number

(###)

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Date of Birth *

Please enter the Date of Birth

MM

DD

YYYY

Services *

Which of our services are you interested in?

SAS Social Skills Program (8-12 years)

PEERS Social Skills Program (Teens 13-17 years)

PEERS Social Skills Program (Young Adults 18 - 35 years)

Friendship & Communication Bootcamp

Dating Bootcamp

Bully Proof Bootcamp

Tuning into Teens (Parent Program)

One to one psychology services

Minecraft Social Skills Program

Minecraft Confidence Building Workshop

NeuroACT Stress Management Program

The Social Club

Which social group/s are you interested in?

The Lab (Gaming Club)

Play, Make & Express (Art Club)

Play, Move & Explore (Music, Dance & Movement)

Lego Club (Bricks 4 Kidz)

Well-Being Wednesdays

Preferred Communication *

Please let us know the best way to contact you

Phone

Email

Phone or email