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 Procedures and Photo Release form are also required.

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
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