TRIAL ECIP Free TrialPlease fill in the form with the required information, we will contact you as soon as possible. Parent's Name & Surname * Child's First Name * Child's Surname * Child's Date of Birth * What year will your child commence school? * Email * Phone * Phone 2 (Optional) What are your main concerns with your child? * Does your child have a diagnosed disability or special needs? If yes, please provide relevant details below Is English your child's first language? If not, please specify. * Does your child have any ongoing medical concerns? *E.g. Allergies, asthma, etc. If yes, please provide relevant details. Please note, children must be toilet trained to join the program. *My child is toilet trained. Please note, children must be immunised to join the program. *My child is immunised (up to 3.5 - 4 yrs old). I am aware that I am required to return an email questionnaire to help the ECIP team better support my child on his/her trial day. Yes Free Trial Preferred Date * Topic and Focus Areas Monday - Information Processing Tuesday - Focus and Attention and Memory Wednesday - Motor Skills Thursday - Emotional Regulation and Impulse Control Friday - Social Skills and power of play *Please note: although we offer a daily focus our team ensures that we incorporate all 5 developmental areas every day. How did you find out about us? * Before the trial:* Once you receive your email questionnaire, an ECIP facilitator will be in contact to confirm your preferred trial date. On the day of the trial:· Please arrive at Kids OT reception at 9am, and our staff will accompany you and your child to the ECIP room. · Please return to the ECIP room at 11:50am to discuss the trial with the ECIP facilitators. Please note that parent supervision cannot be accommodated. · Bring morning tea in a bag and a drink bottle- note that our ECIP room is a nut & egg free zone. VerificationPlease enter any two digitsExample: 12This box is for spam protection - please leave it blank