REGISTRATION FOR CHILDCARE

DATE:

FAMILY NAME:

 

CHILD'S NAME:                                                     DIAGNOSIS:

 

CHILD AGE:                                                          MEDICAL CARE NEEDED:

 

ADDRESS:                                                     CITY:                                                    ZIP CODE:

 

PHONE:                                                        EMAIL:

 

CHILD CARE SERVICES NEEDED:

 

THERAPY SERVICES NEEDED:

PLEASE COMPLETE AND PRINT OFF THIS REGISTRATION FORM AND MAIL WITH A NON-REFUNDABLE REGISTRATION FEE OF $40.00 TO:

The Golden Key Center for Exceptional Children, Inc

1431 30th St NW

Canton Ohio  44709

Any questions please call 330-493-4400