350 Baltimore Annapolis Boulevard
Severna Park, MD 21146
410-647-1503

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: ___________________