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1.
Add your details
*
Child's First name
*
Child's Last Name
*
Email
*
Child's DOB
Street Address
City
State
Country
Postal Code
Parent 1 Name
Parent 1 Phone Number (1st time attending event)
Occupation/Employer (1st time attending event)
Parent 2 Name (1st time attending event)
Parent 2 Mobile Phone Number (1st time attending event)
Parent 2 Home Phone Number (1st time attending event)
Parent 2 Email address (1st time attending event)
Parent 2 Occupation/Employer (1st time attending event)
How did you hear about the program? (1st time attending)
What are your child’s diagnosis and challenges? (1st time attending)
What can your child do [ e.g. gross and fine motor skills, speech, social skills]
What do you hope to see next in your child’s development?
Has your child received physical / occupational/ or behavioral therapy or any other developmental modalities and what changes did you observe in your child?
Please describe any illness, accident, or muscular/skeletal problem and pain that has required medical attention?
Please check all of the following that apply to your child:
Allergies/Asthma/Sinus
Bone Joint Desiease
Cardiovascular/Heart
Chronic Pain
Diebetes
Digestive
Dizziness
Headaches
High/Low Blood RR
Respiratory/Lungs
Scoliosis
Seizures
Constipation
Skin Disorders
Vision Impairement
Other medical conditions (please specify below)
Other medical conditions
Please indicate two preferred time slots per each day with at least 45 min gap in between: 9:30, 10:15, 11, 11:45, 1:30, 2:15, 3, and 3:45. Please note we may not be able to accommodate these.
Would you like to request a financial aid application form?
Yes
*
Please check the following acknowledgements:
I understand that the lessons given by the ABM/NeuroMovement Practitioner (hereafter the "Practitioner") are educational only. They are not medical and do not replace appropriate medical care.
I agree to let the Practitioner know immediately if I see my child experiencing any discomfort.
I affirm that I have notified the Practitioner of all known medical conditions and injuries of my child and will inform him/her of any changes in my child’s health and medical condition
I respect the time and effort each practitioner donates to COPEC and I am committed to arrive on time for my child’s lessons unless there is an emergency that prevents me from doing so.
If I cancel late or don’t come without notification my child may not qualify for this program in the future.
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2.
Event Policies
CoPEC Community Lesson Weekend - May 3-4
May 03, 2025, 7:30 AM PDT – May 04, 2025, 2:30 PM PDT
Oakland
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