Name: 539 N Lake Ave
Address: 539 N Lake Ave, Pasadena, CA 91101
Telephone: (626) 844-1821

Child's name (first and last)

Parent's name (first and last)

Phone

City where you live:

Preference of Day

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What is your child's school Setting? (SDC, Fully included, Homeschooled, Alternative schooling option)

Child's Birthday including year

Child's Grade

Does your child have an additional Diagnosis? (Autism, Apraxia, etc)

What Club 21 Programs/Events have you previously participated in? ( none, Walk, Stepping Up, etc)

ECAR Waitlist