Phone:
(480) 991-6560

Scottsdale Office:
6865 E. Becker Ln. Ste 101
Scottsdale, AZ 85254
Chandler Office:
932 W. Chandler Blvd. Ste 3
Chandler, AZ 85225
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Summer Programs
Choose a program below:

Summer Registration Form

PSLS Summer Programs
Kamp Talk A'lot
Intensive Apraxia Program
Fast ForWord Intervention
Reading Intervention
Writing Programs
Teen Talk
Summer Registration Form
PEDIATRIC SPEECH AND LANGUAGE SPECIALISTS
SUMMER PROGRAM REGISTRATION FORM

6865 E. BECKER LN. SUITE 101, SCOTTSDALE, AZ 85254
(480) 991-6560
Please fill out then bring in or mail the appropriate fees to the address shown.
Child's Name *:
Child's DOB *: (mm/dd/yyyy)
Parent's Name *:
Address *:
City *:
State *:
Zip *:
Email:
Home Phone: (xxx) xxx-xxxx
Work Phone (Dad): (xxx) xxx-xxxx
Work Phone (Mom): (xxx) xxx-xxxx
Emergency Contact:
Emergency Phone: (xxx) xxx-xxxx
Allergies:
Is your child currently being seen by a speech therapist?
If so, who?
Is your child being seen by any other medical professionals?
If so, who?
PLEASE ENROLL MY CHILD IN THE FOLLOWING PROGRAM(S):
Program 1:
Program 2:
Program 3:
*Please register as soon as possible. Due to our crucial ratio criteria once the classes are full we cannot make any exceptions. Thanks for your understanding in this area. We are looking forward to a great summer!
*PRO-RATING FOR VACATIONS ONLY ACCEPTED PRIOR TO MAY 15TH. WE ACCEPT MASTERCARD, VISA DISCOVER AND AMERICAN EXPRESS
*required fields to be filled in

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