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All participants will be asked to sign a confidentiality form
Helping Hands for Fetal Alcohol Spectrum Disorder
22 Grand Forest Drive
Barrie, Ontario
L4N 7E8
705-791-5802
Fax: 705-726-0335
info@hh4fasd.com
YOUTH GROUP REGISTRATION
Name of Child: _______________________________________________________________
Address: ____________________________________________________________________
Telephone number: _____________________ Email: _________________________________
D.O.B. ____________________ Developmental Age: ________________________________
Emergency Contact: ___________________________________________________________
Telephone number: _______________________ Relationship: __________________________
What is the level of supervision that the child requires: __________________________
Are there any safety concerns: _____________________________________________
Are there any environmental triggers we should be aware of i.e. loud noises, crowds of people? ______________________________________________________________________
Any other details you feel would be important for us to know? Eg. Who will drop off/pick up from group (id will be required) ______________________________________________________________________
Referring Agency: _____________________ Contact: ________________________________
Address: ____________________________________________________________________
Phone number: __________________________ Email: ________________________
The group is currently running every third Tuesday of each month at the Common Roof 165 Ferris Lane 6:30 – 8:30 p.m. Registration costs are $15.00/session
How did you hear about us? _________________________________________________
WE ARE A NON PROFIT ORGANIZATION AND ALL MONIES COLLECTED IN THE YOUTH PROGRAM GO BACK INTO THE KIDS
