Please print this form, check the programs you are interested in and send to: 

Cisco Center, 350 Baltimore Annapolis Boulevard, Severna Park, MD 21146 or call us at 410-647-1503.

Child Registration

I am interested in the following programs (please print page, check all that you are interested in, and mail or bring to the Cisco Center):

                                 Programs

Please sign my child, ___________________, up for the following programs:


_____ Pre-K Early Intervention Program: (Circle days and times that you want 
          your child to attend)
            2, 3, 4, 5 days a week, AM or PM;
                    AM -    Mon      Tue      Wed      Thu      Fri
                        PM -    Mon      Tue      Wed      Thu      Fri

______ Social/Language Groups: 8 week program; (circle appropriate group)
           3 to 6 year olds        7 to 10 year olds       Toddlers (2 year olds)

______ Art: Sensory/Fine Motor/Language: 8 week program

______ Motor/Language Group: 8 week program

______ Occupational Therapy


______ Individual Speech Therapy Services

______ Mom and Dad's Night Out

_____  Oral/Motor Group

______  Parent Workshops

______  Father's Group

_____  Family and Child Advocacy

________________________________________________________________

I have enclosed the $50 registration fee.

Name: __________________________ Phone: _____________________

E-Mail: ______________________ Cell Phone: ______________________

Child's Name: ________________________ DOB: ___________________