Pre-Registration Form - Autism Learning Center

Child's Name *

Child's Birthdate

Parent(s) Name(s) *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone *

Email Address *

Diagnosis, Date Diagnosed, and By Whom (detail please) *

In current ABA program? *

Name of ABA program

How long in ABA program?

What school system is your child involved in? *

Insurance Carrier *

How did you find out about ALC?