2025 SLATE SUMMER SESSION

First Name

Last Name

Child's Date of Birth

Child is attending as a;

Current School Grade

Check your child's educational setting:

Special Day ClassGeneral Education

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

Yes

Service coordinator's name:

Does your child require toileting assistance?

"Other" specify here

What is a good motivator:

Child's aversions:

First Name

Last Name

Mailing Street

Mailing City

State

Mailing Zip

County

Phone Type

Home Phone

Work Phone

Mobile Phone

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.

To view Rowell's Privacy Policy click the link below:

Rowell Family Empowerment's Privacy Policy

Family Role

Primary Language

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

Emergency Contact's First Name	Emergency Contact's Last Name
Relationship to child	Contact Number

Emergency Contact's First Name	Emergency Contact's Last Name
Relationship to child	Contact Number

2025 SLATE SUMMER SESSION

To view Rowell's Privacy Policy click the link below:

Informed Consent and Acknowledgement