Emerge Club Registration Form
Please note that Emerge Clubs are private pay and will not billed through insurance.
(First, Last)
Emerge is an identify-affirming practice and a safe space. We ask for your child's pronouns so that we may address them in a way that feels comfortable for them and is identity-affirming.
Please include the street address, city, state, and zip code.
This opt in is for company communication regarding scheduling and care, not an opt-in for marketing materials.
If yes, please list below:
Please specify which club
Please include any differences with sensory processing, communication, or social participation.
Please list the names and phone numbers of individuals who are authorized to pick your child up from therapy sessions at Emerge Pediatric Therapy. The staff at Emerge Pediatric Therapy will ask for a photo ID from anyone who is picking your child up from the clinic.