Registration Zone

Dear Parents,

Welcome to the Children’s Valley Development Center!

We are delighted to serve your child and achieve the best version of her/himself.

Please fill out the registration form so we can serve your child better:

Child’s Information:

First Name:

Medium Name(s)

Last Name:

Child's Date of Birth:

Child's Nationality:

Child's CPR/Passport Upload:

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

Child's Diagnosis:

Child's Developmental Challenging/Concerning Behaviors:

Child's Strengths:

Child's Areas/Skills to improve:

Child's hobbies, interests, habits, and preferences either in toys, games, activities, place, people…

Does your child have any food allergies? Please mention it here and provide us information about his diet

Expected Realistic Goals for your child:

What is your main dream to see in your child in order to say that your child has improved?

How many screen time hours does your child consume everyday?

What type of apps/programs/shows/media do you use for your child?

How many quality time hours per day does the father spend with the child?

What type of activities does the father do you do with the child?

How many quality time hours per day does the mother spend with the child?

What type of activities does the mother do you do with the child?

Rehabilitation Assessments and Medical Testing Reports:

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

School/Preschool or Previous Centers Reports:

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Parent’s Information:

Father’s/Guardian’s information:

Father's/Guardian's Name:

First

Middle

Last

Father's/Guardian's Age:

Father's/Guardian's Nationality:

Father's/Guardian's Phone No.:

Father's/Guardian's Email:

Father's/Guardian's Occupation/Job:

Father's/Guardian's Work Company Name:

Father's/ Guardian's CPR/Passport Upload:

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

Does your child have a caregiver:

Yes
No

Caregiver's Name:

First

Last

The Name of the person who will drop and pick your child up:

First

Last

Drop/Pick up person CPR/Passport Upload:

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

Parent’s Information:

Mother’s information:

Mother's Name:

First

Middle

Last

Mother's Age:

Mother's Nationality:

Mother's Phone No.:

Mother's Email:

Mother's Occupation/Job:

Mother's Work Company Name:

Mother's CPR/Passport Upload:

Drag & Drop Files, Choose Files to Upload

Family Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Sibling’s Information:

Number of brothers:

Names of brothers with age:

Number of sisters:

Names of sisters with age:

Emergency Contact’s Information:

Emergency Contact Name:

First

Middle

Last

Emergency Phone No.:

Emergency Contact Email:

Emergency Contact Address:

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact's CPR/Passport Upload:

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

The signature of the parent/guardian who filled the form:

Clear Signature

Rate your experience with us:

The Children's Valley Development Center

Child’s Information:

Parent’s Information:

Parent’s Information:

Sibling’s Information:

Emergency Contact’s Information:

Welcome to the Children’s Valley Center…

Thank you for your time!