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Special Needs Form

We are thrilled to work with children who have special needs. It is a great help to our instructors if you provide details on routines, sensory preferences, and necessary accommodations. You can write a novel or skip every field. We just want to hear about how awesome your child is so that they can have a fun experience at PBJ. After completing this form we can help you set up a game plan that works for your family.

Family Information

* Indicates required field

Parent Name *

First

Last

Town of Residence *

Program Interest *

Email *

Phone Number *

How did you hear about PBJ? *

Student Information

Name *

First

Last

Age *

Birthdate *

Seizures In the Past Year? *

Medical Needs & Allergies *

Lesson Goals *

Learning Style *

Likes, Dislikes, Motivators *

Difficulty with Transitions? *

Vision & Hearing *

Mobility *

Behavior Strategies & Sensory Preferences *

Communication *

Additional Notes or Diagnosis *

Submit

Special Needs Form

Family Information

Student Information

Peanut Butter & Jellyfish