Helping Hands Registration – Intensive Therapeutics

Summer, Fall, & Winter Sessions

View Summer Helping Hands page.
View Fall Helping Hands page.
View Winter Helping Hands page.

Privacy is very important to us. No information sent to Intensive Therapeutics will in any way be distributed or shared without your acknowledgement and consent.

Instructions to complete registration forms:

Complete the Contact, Registration, and Medical information below and submit.
Complete and sign the following two (2) consent forms:
Informed Consent for Therapy Programs Form
Video/Photo Release Form
Consent forms can either be uploaded at the end of this form, mailed to:
Intensive Therapeutics, Inc.
31 Fairfield Avenue
West Caldwell, NJ 07006
OR
emailed to: info@intensivetherapeutics.org
*Forms must be completed, signed, and received at least one month prior to program start.

Registration Information

Child’s Name *

First

Last *

Last

Date of Birth *

mm/dd/yyyy

Age *

Gender

Program Information

Helping Hands Program *

(Once you select a program, session options will appear.)

Camp Session *

Will your child be attending full time?

Please provide modified schedule *

Tier Options *

Add-On Option

Would you like your child to participate in “Pizza Fridays”? *

Yes

Contact Information

Parent’s Name *

First

Last *

Last

Email *

Primary Phone *

Primary Phone Type *

Alternate Phone #1 *

Alternate Phone #1 Type *

Alternate Phone #2

Alternate Phone #2 Type

Address *

Address Line 2

City *

State * State

Postal Code *

Country

Medical Information

Is your child on medications? *

Yes

Types of medications *

Does your child have allergies? *

Yes

Please list allergies *

Any other pertinent information?

Family Goals

What are one or two realistic / functional goals you would like to see your son / daughter achieve during this program?

Consent Forms

Please upload completed Informed Consent and Video/Photo Permission forms here. *

Maximum upload size: 104.86MB

Please confirm below: