ACET Registration Form

Parent/ Guardian Name *

Please use the name of the person that completed the purchase of the ACET sessions on behalf of the child!

First Name

Last Name

Phone

(###)

###

####

ACET Member (Teen's) Name *

First Name

Last Name

Please check all that apply *

Non-verbal

Able to express needs

Conversational

Needs verbal directions repeated

Needs directions demonstrated

Needs assistance to follow directions

Fine motor challenges

Gross motor challenges

Needs mobility assistance

Sensitive to loud noise

Sensitive to fluorescent lighting

Sensitive to smells

Sensitive to certain foods

Cannot tolerate touching certain things

Toileting independent (if not independent, caregiver must attend!)