First-time LEGO Club Registration

Lego Club Registration Form This is the signup information sheet you will use to sign your child up  to belong to the Lego Social Club. The information you post here will  be sent directly to Patty and will not be made available publicly.
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. *	1 2 3 4 5 6 7 8 9 10 11 12 MM / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY
Parent or Guardian's Name *	First Last
Phone *	### - ### - ####
Cell Phone	### - ### - ####
Address *	Street Address Address Line 2 City State / Province / Region Postal / Zip Code Antigua and Barbuda Aruba Bahamas Barbados Belize Canada Cook Islands Costa Rica Cuba Dominica Dominican Republic El Salvador Grenada Guatemala Haiti Honduras Jamaica Mexico Netherlands Antilles Nicaragua Panama Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago United States Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Greece Hungary Iceland Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom Vatican City Afghanistan Bahrain Bangladesh Bhutan Brunei Darussalam Myanmar Cambodia China East Timor Hong Kong India Indonesia Iran Iraq Israel Japan Jordan Kazakhstan North Korea South Korea Kuwait Kyrgyzstan Laos Lebanon Malaysia Maldives Mongolia Nepal Oman Pakistan Palestine Philippines Qatar Russia Saudi Arabia Singapore Sri Lanka Syria Taiwan Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Vietnam Yemen Australia Fiji Kiribati Marshall Islands Micronesia Nauru New Zealand Palau Papua New Guinea Samoa Solomon Islands Tonga Tuvalu Vanuatu Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Democratic Republic of the Congo Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Gibraltar Guinea Guinea-Bissau Cote d'Ivoire Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland United Republic of Tanzania Togo Tunisia Uganda Zambia Zimbabwe Country
Email Address *
Tell me about your child. What behavior issues do you have at home or at school? For example: non-compliance, sensory meltdowns, aggression, oppositional, rigid. *	<br />
Previous diagnosis *	If no official diagnosis, please type in "does not apply."
What type of school setting is your child enrolled in? *	Mainstream classroom, no aide Mainstream classroom, one on one aide Homeschool Special education classroom more than 50% of the time
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? *	<br />
What are your child's interests? What does he/she like to do? *	<br />
Current Lego play skills *	Plays with sets   plays freestyle   Group projects   Limited Lego skills
Give me any information about your child's play skills. *	<br />
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. *	<br />
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.	<br />
Names and ages of siblings	<br />
Please list any allergies or health concerns *	<br />

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