At Home Speech Therapy for Children and Adults in Northern NJ

Providing Our Clients With the Freedom to Speak
At Home Speech Therapy for Children and Adults in Northern NJ

Little Talkers

Spend some quality time with your little talker at this fun and interactive 4-week class.  Encourage your child's speech and language development through social games, song, and stories.  The class is facilitated by Courtney Caruso, M.S., CCC-SLP, a certified and licensed bilingual speech-language pathologist.  


Spaces are limited!  Register today!  

Registration deadline is May 27


 

LITTLE TALKERS REGISTRATION FORM

Please print clearly

 

Participant Name: _________________________________________________________           

 

Male/Female: __________________ Date of Birth: _______________ Age: __________

 

Parent/Guardian Name: ____________________________________________________

 

Address: ________________________________________________________________

 

Phone (home): _________________________ (cell): ____________________________

 

Do you have any concerns with your child’s speech or language skills?  Yes  No

 

If yes, please describe: _____________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

A $50 check (full payment) made payable to Liberty Speech Associates must be included with this registration form. 

Check and registration form should be mailed to PO Box 555, Blairstown, NJ 07825.  Spaces are limited and spots

will be filled on a first come first serve basis.  Registration deadline is May 26, 2017.  You will be contacted to

confirm your registration.

 

Important - Hold Harmless Release

I, __________________________, hereby grant permission for my child, __________________________,

to participate in the Liberty Speech Associates Little Talkers program. I waive and release all rights and

claims for damages against Liberty Speech Associates, Kaleidoscope Enrichment, and their prospective

employees and agents for any and all injuries, which may be suffered by my child or myself while

participating in the program.

Parent/Guardian Signature: __________________________________ Date: __________

Parent/Guardian Name: _____________________________________