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Life's WORC Family Center for Autism

Programs & Services
About Us
News
Events
Contact Us
- Contact Us
- Pre-Register

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Pre-Register

Name of Participant
First Last
DOB
Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact
Home Phone Number
Parent Cell Phone
Diagnosis
Email Address
Applying For
Apply As
Does your son or daughter have any allergies (food or medication)?
- Yes
- No
Is your son or daughter independent in toileting skills?
- Yes
- No
Does your son or daughter communicate independently? What form of communication do they use?
- Yes
- No
Is your son or daughter on any medication?
- Yes
- No
If Yes, please specify
What are their likes or dislikes?
Does your son or daughter have difficulty with transitioning from activity to activity?
- Yes
- No
Does your son or daughter have a history of aggression towards others?
- Yes
- No

Location

1517 Franklin Avenue
P.O. Box 7587
Garden City, NY, 11530-0726

Contact

(T) 516-355.9400
(F) 516.355.9401

Engage

1517 Franklin Avenue
PO Box 7587
Garden City, NY, 11530-0726

(T) 516-355-9400
(F) 516.355.9401

[email protected]

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