Emerge Club Registration Form Fill Out the Club Registration Form Summer 2023 Club Registration Form Please note that most of our Clubs are private pay and will not billed through insurance. The exceptions for Summer 2023 Clubs are AAC Adventures, Terrific Toddlers, and Reading & Succeeding. Today's Date MM slash DD slash YYYY Please check the box of the club you are registering your child for:* Terrific Toddlers - Carrboro AAC Adventures - Durham Preschool Power - Durham Preschool Power - Cary Reading & Succeeding Social Butterflies - Durham Social Butterflies - Carrboro Social Scouts - Durham Social Scouts - Cary Social Scouts - Carrboro Girl Talk - Durham Girl Talk - Cary Social Sleuths - Durham Social Sleuths - Cary Social Sleuths - Carrboro Setting The Stage - Durham Life Skills - Durham Which Session for Preschool Power Durham?* Session 1: Weeks of June 12, 19, 26, July 10, 17 Session 2: Weeks of July 24, 31, August 7, 14, 21 Which Level for Reading & Succeeding?* Level 1 (Kindergarten) Level 2 (First Grade) Level 3 (Second Grade) If your child is not attending therapy sessions at Emerge, we will be in touch with you to set up a brief free screening to determine if this program is a good match for you child.Child's First Name* Child's Last Name* Date of Birth* MM slash DD slash YYYY Child's Pronouns e.g. she/her, he/him, they/them, etc.Child's Age If you are a current Emerge client with one of our in-network insurance providers (NCMC, Tricare, etc.), check "yes" and our intake coordinator will reach out to you with more information.* Yes No Caregiver(s) Name and Relationship to Child* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Cell PhoneEmail Address* How did you hear about this club?* My child attended (school) this year. S/He will be attending (school) in the fall. Grade Does your child receive any special services at school?Please list allDoes Your Child?Attend therapy sessions at Emerge? Yes No Receive services elsewhere? Yes No If so, where? (Please attach a copy of a recent report.) Have any allergies? Yes No If yes, please list:Does your child currently receive psychological services? Currently Previously Where?I am interested in enrolling my child in a club program because (please specify which club):My child demonstrates challenges regarding:Strategies that help my child:List any sensory processing challenges that your child has:List any communication and/or social challenges that your child has:List any diagnoses (formal or informal) that your child has:List any dietary restrictions that your child has: Δ
