FALL/WINTER SESSION

May we text you?

YesNo

By selecting yes, you agree to receive texts from Rowell Family Empowerment of Northern California at the mobile number you provided. Message and data rates may apply. Text STOP to unsubscribe from messages at any time. By subscribing, you agree to get text messages from Rowell about services we provide.

First Name (Legal)

Last Name (Legal)

Date of Birth

Child's current diagnosis is:

Other/multiple disabilities

Check your child's educational setting:

3 to 4 year olds/At homeSpecial Day ClassGeneral Education Home School

Do you have a current Individual Education Plan (IEP)?

YesNo

Does your child have a Behavior Intervention Plan?

YesNo

Is this child a FNRC Client? (If yes, specify Service coordinator below)

Yes

Service coordinator's name:

Child's UCI# (Regional Centers Client ID# on your IPP or IFSP)

Is your child on a Self Determination Plan?

YesNo

Who is your FMS

Primary mode of communication is:

VerbalPEC'sASLOther (specify below)

"Other" specify here

Communication method:

Primary Care Doctor

Phone Number

Preferred Hospital, in case of Emergency

Does the child have any allergies?

Yes

I the parent/legal guardian, grant Rowell Family Empowerment all rights to use images of my child or myself as indicated by the check boxes below. Rowell may use the images in any way deemed necessary, without limitation. I also irrevocably waive any right I may have to inspection or approval of any of the deliverables or uses contemplated in the Release. I, the parent/legal guardian hereby irrevocably release Rowell Family Empowerment from any liability, costs or expenses arising by virtue of the use of such things. This release shall be binding with restriction as to time or otherwise upon the family and his/her theirs, executors, legal representatives, successors and assigns, as the case may be.

Yes, I agree for photos to be taken of my childNo, I DO NOT want photos taken of my child

Contact's First Name	Contact's Last Name
Relationship to Attendee	Contact Number

Contact's First Name	Contact's Last Name
Relationship to Attendee	Contact Number

FALL/WINTER SESSION

SLATE Social Skills Training Groups

Child's Social/Behavioral Information

Informed Consent and Acknowledgement