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UCP of Greater Dane County

Understanding Disabilities, Creating Opportunities, Promoting Community

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Connect the Tots Registration

Child's Name *

First

Last

Date of Birth *

Race (optional):

Ethnicity (optional):

Primary Language:

Language:

Parent/Legal Guardian Name *

First

Last

Additional Parent/Legal Guardian Name

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

By checking the box, I give UCP staff permission to contact me in the following ways:

Phone
Text
Email

I would like to register for Connect the Tots sessions in the following community: *

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: *

Entire 8 week series (do not check additional boxes)
04/22/2025 - Animal Fine Motor Fun
04/29/2025 - Animal Movement Adventures
05/06/2025 - Animal Cognition and Discovery
05/13/2025 - Animal Emotions and Social Skills
05/20/2025 - Animal Self-Help Skills
05/27/2025 - Animal Vocabulary and Speech
06/03/2025 - Animal Adventures
06/10/2025 - Animal Action Time

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: *

Entire 8 week series (do not check additional boxes)
04/24/2025 - Animal Fine Motor Fun
05/01/2025 - Animal Movement Adventures
05/08/2025 - Animal Cognition and Discovery
05/15/2025 - Animal Emotions and Social Skills
05/22/2025 - Animal Self-Help Skills
05/29/2025 - Animal Vocabulary and Speech
06/05/2025 - Animal Adventures
06/12/2025 - Animal Action Time

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: *

Entire 8 week series (do not check additional boxes)
04/25/2025 - Animal Fine Motor Fun
05/02/2025 - Animal Movement Adventures
05/09/2025 - Animal Cognition and Discovery
05/16/2025 - Animal Emotions and Social Skills
05/23/2025 - Animal Self-Help Skills
05/30/2025 - Animal Vocabulary and Speech
06/06/2025 - Animal Adventures
06/13/2025 - Animal Action Time

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: *

Entire 8 week series (do not check additional boxes)
04/22/2025 - Animal Fine Motor Fun
04/29/2025 - Animal Movement Adventures
05/06/2025 - Animal Cognition and Discovery
05/13/2025 - Animal Emotions and Social Skills
05/20/2025 - Animal Self-Help Skills
05/27/2025 - Animal Vocabulary and Speech
06/03/2025 - Animal Adventures
06/10/2025 - Animal Action Time

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: *

Entire 8 week series (do not check additional boxes)
04/21/2025 - Animal Fine Motor Fun
04/28/2025 - Animal Movement Adventures
05/05/2025 - Animal Cognition and Discovery
05/12/2025 - Animal Emotions and Social Skills
05/19/2025 - Animal Self-Help Skills
06/02/2025 - Animal Vocabulary and Speech
06/09/2025 - Animal Adventures
06/16/2025 - Animal Action Time

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: *

Entire 8 week series (do not check additional boxes)
04/21/2025 - Animal Fine Motor Fun
04/28/2025 - Animal Movement Adventures
05/05/2025 - Animal Cognition and Discovery
05/12/2025 - Animal Emotions and Social Skills
05/19/2025 - Animal Self-Help Skills
06/02/2025 - Animal Vocabulary and Speech
06/09/2025 - Animal Adventures
06/16/2025 - Animal Action Time

This Session's theme is "Wild and Wiggly Wonders!" We are registering for the following dates: (copy) *

Entire 8 week series (do not check additional boxes)
04/25/2025 - Animal Fine Motor Fun
05/02/2025 - Animal Movement Adventures
05/09/2025 - Animal Cognition and Discovery
05/16/2025 - Animal Emotions and Social Skills
05/23/2025 - Animal Self-Help Skills
05/30/2025 - Animal Vocabulary and Speech
06/06/2025 - Animal Adventures
06/13/2025 - Animal Action Time

Total

$0.00

Bill Registration to: *

Family (Private Pay)
CLTS Waiver (Children's Long-Term Support)
Other (see below)

Case Manager Name *

Case Manager Email *

Case Manager Phone

Bill to Other (Please Explain):

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