Child 4-Characteristics Form for Teen Huddle PTO

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Child 4 -Characteristics Form Teen Huddle Parents Time Out

Child 4-Characteristics Form - PTO

Parent Name *

Parent Last Name *

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Phone 1 *

Alternate Cell:

Alternate E-mail:

Email *

First Name *

Preferred Name

Birth Date

Age *

Gender *

How does this child communicate? Example: verbally, sign language, PECS, gestures only. *

Is this child toilet trained? *

Yes

How do they let you know they need to go to the restroom? *

Allergies

Are there any behaviors this child might engage in that we should know about? ie., Running away from adults, aggression toward adults or peers, putting things in their mouths, etc. *

Yes

If Yes, please specify:

Provide any other information that you feel would make PTO more enjoyable for your child on the autism spectrum.

Additional Notes or Comments:

Data Privacy & Consent

Yes, I would like to receive communications from Hope For Three by email.

Yes, I would like to receive communications from Hope For Three by phone.

Yes, I would like to receive communications from Hope For Three by SMS.

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