Rock The Summer 2020 Therapy Registration

Student Name *

First

Last

Age *

Date of Birth *

Parent/Guardian *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Physician *

Physician Fax Number *

Please Select Preferred Session: *

Please Select Desired Location: *

** Summer Hours: M - Th 8am-5pm **TLS will be closed June 29th - July 2nd

Please Select Desired Therapies: *

Please List Funding Source(s):

Please List First Choice for Day(s) and Time(s) Desired: *

Please List Second Choice for Day(s) and Time(s) Desired: (copy) *

*Specific Schedules Will Vary By Location. **Summer Registration DUE APRIL 2ND ***For Questions, please contact therapy@thelearningspectrum.com