Child Enrollment Form

childenrollmentform_banner

Here you will find the forms needed in order to sign your child up for AiN. If you have a child with special needs and would like to apply for our program, please fill out the annual enrollment form and submit it.

Please also submit a copy of the doctor’s note or a current copy of the IEP, or other forms showing child’s eligibility.  Once we receive your enrollment form, we will set up a phone interview with the family. We will invite you to come to a Revive or Social Club event so you can view the program and we can meet the child.

Note: A signed Photo Release form is required. Please review our Terms and Conditions page. You will agree to these terms on the Enrollment Form.

Child Enrollment Form

Child's Information

Medical/ Health Considerations

Child's Method of Communication

Check all that apply

Child's Education Skills

Check all that apply

Parent's Information

In Case of Emergency

Digital Signature

Full Name
Full Name
optional
Sending