Class Registration

Please fill out the form below to register for Sensory Bounce® Class

RATES

Sensory Bounce® Classes are $100 per class.

PLEASE NOTE

For Sensory Bounce® Therapy Sessions:

Classes with fewer than 4 participants may be canceled or combined with other like classes
We reserve the right to dismiss any child who is disruptive to the class
To maintain consistency for all participants, initial registration is an 8-week commitment, after which participants may opt out on or before the 25th day of the month
Sensory Bounce® requires class participants to make a concerted effort to attend ALL classes in order to maintain their spot in the class
Participants will be responsible for the cost of the class if Sensory Bounce® is not notified of a cancellation 24 hours before the class
Sensory Bounce® will direct bill for participants who have received approval to attend Sensory Bounce® as a community class
Credit cards for self-paying members will be charged on the first day of every month for the following month
There are no refunds once registration form is submitted UNLESS THE CLASS INSTRUCTOR FEELS THE CHILD IS NOT A GOOD FIT OR WILL NOT BENEFIT FROM THE CLASS
Sensory Bounce® offers a limited number of scholarships

REGISTER HERE for Classes

Choose a Program *

Parent Full Name *

First Child’s Full Name *

Child Birth Day *

Current Grade *

Diagnosis *

Is your child verbal? *

Can your child follow basic directions? *

Is your child aggressive? *

Has your child ever been without a parent?*

Second Child’s Full Name *

Child Birth Day *

Current Grade *

Diagnosis *

Is your child verbal? *

Can your child follow basic directions? *

Is your child aggressive? *

Has your child ever been without a parent?*

Name of Your Broker *

Broker’s Contact Number *

Extension *

Broker’s Email *

Fiscal Intermediary’s Phone Number

Extension *

Fiscal Intermediary’s Email Address *

Will you be paying for the class and submitting for reimbursement ? *

Yes No

Would you like us to direct bill ? *

Yes No

Contact Number *

Email Address *

Address

State/Prov *

City *

Zip Code *

How did you hear about us ? *

I will be joining the parent support group *

I will be joining other parents in the group meeting room

Yes, I would love to

No, thank you

Referral Details *

Please provide any information you feel we should know about your child such as specific issues/fears/diagnosis.

Have Questions ?

[email protected] +1-201-794-7700