UP Early Intervention Clinic Inc Online Registration

Registration

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Welcome to UP Early Intervention Clinic Inc! All of our classes include a sibling discount of 25% off for 2nd child registered A reduced rate may be available for those who want to participate but are not able to due to financial constraints; please contact us for availability of supported registration. Please fill out the following information to begin the registration process

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address

City

State

Zip

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from UP Early Intervention Clinic Inc. Standard message and data rates apply. Reply STOP to opt out

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from UP Early Intervention Clinic Inc. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Allergies (Leave blank if NONE)

Diagnosis

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Allergies (Leave blank if NONE)

Diagnosis

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Allergies (Leave blank if NONE)

Diagnosis

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Allergies (Leave blank if NONE)

Diagnosis

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Allergies (Leave blank if NONE)

Diagnosis

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

Country

City

State

Zip

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)