Teen Night Out |

Teen Night Out

2017 dates:

1/20, 2/24, 3/24, 4/21, 5/19

All Teen Night Out events take place at:

Forest Road Park Building, 158 Forest Rd, Fanwood, NJ 07023

A peer-mentor, GROUP program for teenagers with special needs, held monthly, focusing on social skills, interaction and fun.

Check out the video below made by, Alexandra Jackman, our peer-mentor leader of Teen Night Out!!

Teen Night Out Registration Form

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/Medical Information form below and click the send button.
Print out the following two forms:
a. Consent to Attend form
b. Video Permission form
Complete and sign these 2 forms and mail them to:
Intensive Therapeutics, Inc.
274 South Avenue
Fanwood, NJ 07023
OR, bring both forms, completed and signed, on the first day of the program.

Desired Starting Date

Registration Information

Child's Name *

First

Last *

Last

Date of Birth *

Age *

Gender *

Parent's Name *

First

Last *

Last

Home Phone *

Cell Phone *

Phone Back Up

Email *

Address *

Address Line 2

City *

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?

History

Please briefly describe past attempts of participation in community activities or social events.

Family Goals

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

Note: This message and any attachments are intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender by replying to this message and permanently deleting it from your system.

Please confirm below: