SOCIAL COMMUNICATION GROUPS
Serving Children from Preschool to High School
To develop social language around play/recreation
Problem solving and small group routines

Registration Date:      ______________________________________________  Grade:    _      Age:         

Child’s Name:      ___________________                ___________     Date of Birth:                         _                  
                                                                                                                                                                                                                            (mm/dd/year)
Telephone: (         )  ____________                ____   Cell #:______________________________________

School: ________________________                ___     ________                                                                     __

School S-LP Name:                                                          Phone #:                                                                                 

Parent Name(s):      ________________                ____________________________________        ____

Address:     ________________                ______________________                                                               

City:      _______________                                   _____      Province:  _          Postal Code:   _    _______        

E-mail:       __________________                __________________________________________               

Does your child have any special interests? ___________                _____________________________

_____________________________________                ______________________________________

Does your child have any allergies or medical condition?_________                _____________________

________________________________________                ___________________________________

Policy Acknowledgement and Acceptance

Speech and Language Services and its instructors do not assume any liability for any injuries incurred      
as a result of activities.

I have read the policies outlined and agree to the terms and fees outlined within.

Signature:      __________________        _______________    Date:      _________        ______________

Please contact Dianne Milsom for group availability before registering for the group.

    Consultation, screening, follow up, reporting, etc., will be charged at the rate of $115.00 an hour.
Phone: 604-271-7523
Fax: 1-866-565-9842  
E-mail: dmilsom@shaw.ca  
Remit to:   Dianne E. Milsom, M.S., SLP(C)                  
Registered Speech/Language Pathologist                      
Unit #110 – 3671 Chatham Street                            
Richmond, BC V7E 2Z1


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Please indicate the group you would like your child to attend:
                                     
Spring Social Communication Group - Please check with Dianne Milsom for times
10:30 – 12:00 PM  - April 10, 17, 24,  May 01, 08, 15, 29, June 05, 12, 19, 2010

Spring Saturday Teen Group - Please check with Dianne Milsom for times
April 10, 17, 24,  May 01, 08, 15, 29, June 05, 12, 19, 2010

Spring Friday Night Fun Group
6:30 – 8:00 PM - April 09, 16, 23, 30,  May 07, 14, 28, June 04, 11, 18, 2010

Spring Break Language Booster Group - Please check times and dates with Dianne Milsom
10:30 – Noon   -   March 22, 23, 24, 25, 26, 27, 2010