SENSORY MOTOR SOCIAL GROUP 21 / September Uncategorized Rhonda Osisek 0 Comments Sensory Motor Social Group REGISTRATION FORM Child Name(Required) First Last Parent Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) COSTCURRENTLY ENROLLED Social Butterflies Club/Monarch Club Member Fee: $495.00DATES: October 6, 13, 20, 27 November 3, 10, 17 December 1, 8, 15 FEE: $49.50 per 60 minute session *Fee INCLUDES Sensory Processing Assessment and interpretation as well as materials.Non Member Fee- $640.00DATES: October 6, 13, 20, 27 November 3, 10, 17 December 1, 8, 15 FEE: $55.00 per 60 minute session and one time $90.00 assessment fee *Fee INCLUDES Sensory Processing Assessment ($90.00)and interpretation as well as materials.TIME OPTIONSTime Preference(Required)Please let us know your time preference. We will do our best to schedule your child during the time you select. WEDNESDAYS 4:15-5:15 WEDNESDAYS 5:30-6:30 PAYMENTPayment Preferences(Required) Please bill me for the entire Fall Session for a 10%discount (Due by October 1) Please Bill me in 2 installments (Due October 1 and November 1) DEPOSIT(Required)Deposits paid will be applied to your child's tuition. Price: Credit CardCard Details Cardholder Name Consent(Required) I agree to the following policy.I understand that by registering my child for this group I agree that payment is due PRIOR to my child beginning group. I understand that once my child is enrolled, Social Learning LLC (dba Social Butterflies Club) cannot pro-rate tuition due to missed days or late arrivals. I understand that if for some reason my child must withdraw from the program, a 50% non-refundable processing fee will be deducted. I understand that this program is a therapeutic program and requires consistent attendance to ensure progress with goals and objectives. By clicking the button, I agree to the above-stated information.EmailThis field is for validation purposes and should be left unchanged.