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HAPPY PLACE SPEECH SERVICES Inc.

Books to Bikes Community Program
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Books to Bikes Community Program Forms

Books to Bikes Community Program

Child's First name

Child's Last name

Email*

Phone

Birthday

Month

Day

Year

Grade Level/School Name

Why do you want your child(ren) to participate in the Books to Bikes Program ?

Has your child(ren) ever participated in speech therapy or had speech delays?

Does your child(ren) have an Individualized Education Plan (IEP)?

Reading Level for FAST (Florida Assessment of Student Thinking)

Level 1

Level 2

Level 3

Level 4

Level 5

Register Here

Forms for Parents

Contact information

Child First name*

Child Last name

Parent First Name*

Parent Last Name

Phone

Emergency Contact information

Photography consent & release form

Child First name

Child Last name

I hereby give my consent to use my photographs according to the Terms & Conditions.

Confirm with Parent Initials*

Health declaration

Parents please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Has your child suffered from a medical condition, illness or injury in the past year?

No

Yes

Did your child have any concerns with speech and language development? (i.e. Delayed speech)

Initials*

I declare that the info I’ve provided is accurate and complete.

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www.happyplacespeech.org

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