919-756-6766

​From Interdependence to Immersion to Independence (III)

                      
Application

Class Registration
Will Begin Winter 2018

The Shelva's Help Programs Application 
  
Course   (Mondays and Thursdays)  or (Tuesdays and Fridays)  Course Start Time 8:00am   10:00am
 
Please return your completed application to:  shelvashelp@gmail.com

INDIVIDUAL INFORMATION  Male or Female_____________________________
Name:  _____________________________________________________________________________   Date:  _________________________
Address:  ____________________________________ City:   _____________________________________ State:  _____ Zip:  ____________
Phone:  (primary)   _______________________   Home Work:   _______________________________________________________________    
Mobile: (secondary) ______________________  Email: ______________________________________________________________________
2. PARENT OR GUARDIAN INFORMATION
Name:  ___________________________________________________________________________     Date:  __________________________
Address:  ____________________________________ City:   ___________________________________ State:  _____ Zip:  _______________
Phone: (primary)   _______________________   Home Work:  _________________________________________________________________    
Mobile: (secondary) __________________   Email: __________________________________________________________________________
3. EMERGENCY CONTACTS
Name:  _______________________________________________________________   Date:  _________________________________________
Address:  ____________________________________ City:   _______________ State:  ___ Zip:  _______________________________________
Phone: (primary)   _______________________   Home Work:  ___________________________________________________________________    
Mobile: (secondary) __________________   Email: ____________________________________________________________________________
Name:  _______________________________________________________________   Date:  __________________________________________
Address:  ____________________________________ City:   _______________ State:  ___ Zip:  _______________________________________             
Phone: (primary)   ________________________   Home Work:  __________________________________________________________________    
Mobile: (secondary) __________________   Email: ____________________________________________________________________________
4. ACCESSIBILITY CONCERNS   Are there any additional concerns about which may impact your access and safety? (For example stairs, heights, etc.)
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
5. ANY ADDITIONAL INFORMATION _____________________________________________________________________________________
_______________________________________________________________________________________________________________________
Payment  One Class $27_____________  Sixteen Classes $500_______________   Scholarship____________________________
Name listed on credit or debit card (First Name)_________________________________________( Last Name)______________________________
Credit Card________  Credit Card Number______________________________         Expiration Date_____________   Security Code__________
Cancellation Clause. __________ I agree to notify Shelva’s Help within 14 days of the first class of course if I will not be able to attend the program.   

Signature:______________________________________________________________________________ Date:_____________
The Shelva’s Help is committed to awarding scholarships to locations which service the 1 in 5 persons with disabilities or limited physical challenges as well as the 1 in 58 persons with autism providing more opportunities for family fun.