Social Stirring Registration

Full Name:*

Email:*

Name of Child Participant:*

Please list all allergies below:

Date of Birth of Child Participant:*

Phone:*

Address:*

City/State/Zip:*

How did you hear about this class?

Current Client of ECS:*

Yes

Emergency Contact Information:

Contact Name:*

Relationship:*

Contact Phone Number:*

Questions, concerns, or to register over the phone, call our office 610-282-5735 or email [email protected]

Because this group is therapeutic in nature, each person registering will be sent a sign-in to our client portal, Therapy Appointment. In Therapy Appointment you will be able to pay for the group online or you may call the office at 610-282-5735.

For groups requiring pre-registration, no-shows or cancellations less than 24 hours will be charged the cost of the group.

Thank you!