LEGO Club Registration Renewal


Lego Club Registration Form (Renewal)





Child's Name *


Put your child's full name here.

Which club are you registering for? *

 Effingham (ages
6-13) 
 Effingham
Teen Group (ages 13-18) 
 Mattoon (ages
6-13) 

Child's Gender

 Male 
 Female 

Child's Age *


Children from ages 5-18 are eligible to register for the ELSC.

Your child's birth date.




MM

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DD

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YYYY

Parent or Guardian's Name




First



Last

Phone




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Cell Phone




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Address




Street Address



Address Line 2



City



State / Province / Region



Postal / Zip Code



Country

Email Address



Do you have any comments about last semester's LEGO Club? Any suggestions? What would you like to see us focus on this semester?
*



Previous diagnosis


If no official diagnosis, please type in "does not apply."

What type of school setting is your child enrolled in?



Check which types of therapy your child is enrolled in:

 Occupational
Therapy 
 Speech
Therapy 
 Applied Behavioral Analysis (ABA) 
 Music or Art
Therapy 
 Therapeutic Listening Program 
 Social Skills
group 
 Swimming 
 Autism Movement
Therapy 
 Other 

What are your goals for the Lego Club? *



What are your child's interests? What does he/she like to do?



Current Lego play skills

 Plays with
sets 
 plays
freestyle 
 Group
projects 
 Limited Lego
skills 

Give me any information about your child's play skills.



Level of expressive language (click which one best applies)

 Echolalia 
 Back and forth
conversational 
 Limited topics 
 Varied and
appropriate 
 Stereotyped (ie: catch phrases or scripting 

Tell me about your child's receptive language. Is he/she able to follow directions? Please explain.



Tell me about your child. His/her strengths and weaknesses, what sort of personality traits he/she has. Tell me anything you want me to know
or anything that might help me better assist him/her.



Names and ages of siblings



Please list any allergies or health concerns *



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