Pacekids Programs ECS Inquiry Form

Child's Full Name

Child's Date of Birth

Child's Gender

Male Female Unspecified

Is your child a Canadian Citizen?

Yes No

Will your child require transportation?

Yes No Undecided

Home Address

Postal Code

Community Name

Phone Number

Email

Parent/Guardian Name

Area of Concern:

Speech Language Pathology Occupational Therapy Physiotherapy Behavioural Strategy Other

If you selected "Other" to Area of Concern:

Diagnosis:

Suspected Confirmed

What is your child's suspected or confirmed diagnosis?

Has your child accessed PUF (Program Unit Funding) before?

Yes No Unsure

If your child has accessed PUF before, where did they attend?

How did you hear about Pacekids?

Please read and confirm to complete your form

Thank you for your interest in Pacekids ECS Programs. We are currently receiving a very high volume of inquiries. Our ECS Coordinators will respond as soon as possible. If this is urgent, please call 403-234-7876.

Pacekids empowers children with diverse needs and their families through excellence in therapy, education, and play.

#89131 3363 RR0001

Contact and Location

South: #130 23 Sunpark Drive SE, Calgary, AB T2X 3V1
North: #808 55 Avenue NE, Calgary, AB T2E 6Y4
Phone: 403.234.7876
Email: [email protected]

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