Child Assessment & Registration Form There was an error trying to submit your form. Please try again. CHILD ASSESSMENT & REGISTRATION FORM We kindly request you to complete this form with careful consideration, as your responses will help us tailor a curriculum specifically designed to meet your child’s unique needs. We want to assure you that we maintain the highest standards of privacy and confidentiality. Your personal information is completely secure with us – Let’s Talk Etiquette will never sell or share your information with advertising agencies, nor will we use it for any advertising purposes. Should you wish to stay updated with our programs and offerings, you have the option to join our mailing list by checking the box below, and the same strict privacy rules will apply to this as well. Our commitment to conducting our program ethically and transparently remains at the core of everything we do. Child’s Full Name * Please enter the full name of the child. This field is required. Child’s Gender * Select the gender of the child. Male Female This field is required. Grade Level * Enter the child’s current grade level. This field is required. Age * Enter the child’s age. This field is required. Class Registration * Select the class the child will be attending. Select an option Beginner Etiquette Intermediate Etiquette Advanced Etiquette This field is required. Parent’s Name * Enter the full name of the primary guardian. This field is required. Relationship to Child * What is your relationship to the child? This field is required. Parent’s Phone Number * Enter contact number for the primary parent. This field is required. Parent’s Email Address * Enter a valid email address for the primary parent. This field is required. Secondary Parent’s Contact (Optional) Enter full name of a secondary contact. This field is required. Secondary Parent’s Phone Number (Optional) Enter secondary parent’s contact number. This field is required. Physical Address Address Line 1 * This field is required. Address Line 2 This field is required. City * This field is required. Postal Code * This field is required. Allergies/Health Concerns (If any) Please specify any allergies or health issues the child has. Emergency Contact Name * Enter the name of the emergency contact. This field is required. Emergency Contact Phone Number * Enter the phone number of the emergency contact. This field is required. Physician’s Name (Optional) Enter the name of your child’s physician. This field is required. Physician’s Phone Number Enter the contact number for your child’s physician. This field is required. Dietary Restrictions (if any) Specify any dietary needs or restrictions. Consent for Photography/Video * I consent to photography/video usage in marketing materials. This field is required. Subscribe to Newsletter Check to receive our newsletter and updates. I enrolled my child/ren in LTE’s program because I would like to: * Understand my child/ren better Help my child/ren better their social skills Help my child/ren feel better about himself/herself Improve my family's dynamics and communication Start enjoying family meals again Improve their level of comfort when visiting family and friends Further their understanding on what it means to be a good host/ess Reinforce the importance of gift giving & receiving, and Thank You Notes This field is required. Skills To Strengthen * Which specific skills would you like your child to strengthen? Basic Manners Introducing, greeting, and addressing adults and peers, covering yawns, pointing, etc. Guest & Host Etiquette Be more aware of what is appropriate and helpful, giving/receiving presents, Thank You notes, etc. Out-on-the-town Manners outside of the home, walking on the street, standing in line at cinema, theatre, grocery store, clothing store, elevator & escalator etiquette, cross-culture etiquette, etc. Friendships, Cliques, and Social Cues What does it mean to be a good friend, why are friendships important and boundaries of friendship, how do make friends, etc. Appropriate and Positive Communication Yes vs. yeah, no vs. nope, I am well vs. I am good; I hate this vs. I appreciate that; Telephone etiquette, etc. Presentation and Public Speaking Speaking clearly, using eye contact, awareness of self-presentation, and connecting with your audience. Table Manners, Level I Proper use of utensils, the social aspect of eating, napkin etiquette, etc. Leadership Skills What makes a good leader, steps of becoming a leader, and styles of leadership. Personal Appearance and Hygiene What clothing items go together, why comb your hair in the morning, how do we see others, and what image do we project. Conversations Skills How to start a conversation, how to have a conversation with an adult, end a conversation, interrupt, introduce people, etc. Teamwork and Sportsmanship Etiquette Being on time, working in teams vs. working in groups, good sportsmanship, etc. Family Etiquette Manners at home, knocking when entering a room, keeping family's private affairs private, family boundaries, etc. Netiquette Rules Etiquette rules for email, texting, Facebook, and Instagram, appropriate and inappropriate ways of using social media, circumstances and times, etc. Table Manners, Level II Proper use of chopsticks, the pace of eating, napkin, etc. Job Interview Skills Professional interview decorum from in-person conduct to emails. Teen Dating Etiquette Knowing how to approach someone, what to say/talk about, etc. This field is required. My child’s strengths are (circle all that apply): * Basic, everyday manners When we have guests, receiving presents, writing Thank You notes When we host an event Out-on-the-town manners Makes lasting and healthy friendships easily Appropriate and Positive Communication Presentation and Public Speaking Good knowledge of proper North American and European table etiquette Leadership skills Personal appearance and hygiene Conversation Skills Teamwork and sportsmanship etiquette Family etiquette Netiquette rules Proper use of chopsticks Job interview skills This field is required. My child has a strong bond with: * Parents: mom / dad / guardian Siblings: brother / sister Grandparents: mother’s side / father’s side Uncle / aunts: mother’s side / father’s side Cousins: mother’s side / father’s side This field is required. Family Activities What activities do you engage in as a family? Current and Desired Household Responsibilities Outline current and desired responsibilities for your child. Specific Concerns Any specific concerns regarding your child’s behavior or social interactions? Goals for the Program * Outline three specific goals you want your child to achieve through this program. This field is required. Acknowledgment of Payment Policy * I understand that full payment is required 48 hours before the class start and the policy regarding the 7-day refund period. This field is required. Signature * Please sign here (Full Name) to acknowledge and confirm your registration. This field is required. Submit There was an error trying to submit your form. Please try again.
