Summer Program

Application Deadline and Instructions

FRIDAY MAY 19TH, 2017

Child's Name:

Age:

Birthdate:

Parents’ Names:

Mother:

Phone:

Email:

Father:

Phone:

Email:

Mailing Address:

Current Speech Therapist & his/her contact information:

Phone:

Email:

Program currently attending (NIPP, ELI, Early Start, Other) and location:

Phone:

Email:

What do you believe is your child’s primary need related to Speech and Language?

Donation Amount Enclosed (suggested $250) $50, $100, $150, $200, $250 or more.
$50.00$100.00$150.00$200.00$250.00Or More

Make check payable to: The California Scottish Rite Foundation

Requested Days and Time: Mon/Wed or Tues/Thurs 9:30am, 10:30am, 11:30am or 1:00pm

We cannot guarantee your requested days and times

Mail or Fax to:

The Erickson Foundation Santa Rosa Rite®Care Childhood Speech Language Center

625 Acacia Lane, Santa Rosa, CA 95409
FAX: 707-539-5905

Questions please call: 707-539-3003 or email: www.cstcsantarosa@gmail.com

CLIENTS WITHOUT DOCUMENTARY PROOF OF ALL REQUIRED IMMUNIZATIONS SHALL NOT BE ADMITTED FOR TREATMENT

Please complete attached application. It is very important that copies of your child’s Speech and Language progress reports and/or evaluations and the latest IEP Goals be included. This summer program does not do evaluations. We will be working from the Speech and Language goals already developed by the referring public school speech therapist and IEP team. Our summer speech program is modeled on the non-intensive preschool program established in the public school. Groups consist of three children. Specific sounds and language structures are targeted. Children enrolled in SDC (Special Day Class) and children with Spectrum Disorders (Autism, Aspergers’s, PPD-NOS) do not benefit from this structured , non-intensive program. These children are better served attending a summer school program offered through the school system. You will be contacted the week of June 2nd for a brief phone conference to confirm acceptance and determine a schedule.