Time 2 Shine Enrollment Application
Date: _____________________________________
Name of Child: Parent(s):_____________________________________________________
DOB: ___________________________ Address:________________________________________________
Gender: M F
Diagnosis: ______________________________________________________________________________
Phone Contact: (H)____________________ (W)______________________ (Cell)___________________________
Siblings: Age:______________________________________
Age:______________________________________
Age:______________________________________
Favorite Activities/Toys:_____________________________________________________________________
Dislikes:________________________________________________________________________________
Allergies:________________________________________________________________________________
Family Goals:____________________________________________________________________________
Communication/Social Skills________________________________________________________________
How does child communicate:
Verbal:__________________________________________________________________________________
Sign/gesture_____________________________________________________________________________
Nonverbal:_______________________________________________________________________________
Examples of vocabulary/Communication style:_____________________________________________________
Hearing status: __________________________Date last tested:______________________________
Behavioral/Communication concerns:____________________________________________________________
Sensory
How does your child respond to:
Movement________________________________________________________________________
Sound___________________________________________________________________________
Visual Stimuli_____________________________________________________________________
Touch/Tactile_____________________________________________________________________
Other Concerns/Comments__________________________________________________________
Daily living Skills
Dressing :________________________________________________________________________
Toileting :_________________________________________________________________________
Feeding/Eating_____________________________________________________________________
Favorite foods:_____________________________________________________________________
Dislikes:__________________________________________________________________________
Feeding Concerns:__________________________________________________________________
Photo Release
I,_________________________________________ , (give / do not give ) permission for my child _______________________
, to be photographed while at Time 2 Shine Therapy and allow photographs to be used for publishing of Time 2 Shine promotional materials.
______________________________________________________
Parent/Guardian Signature Date