Clay White, LLC Therapeutic Programs, Activity Based and Sensory Driven.

New Emergency Contact

Please fill out the form below or fill out the pdf version of the Emergency Contact Form.

the client's birthday

Parent Name and Address

Contact Numbers

Medical Information

including insect bites, medications, food, etc.
Other pertinent medical history (i.e. medical conditions, seizure activity, etc.)
Anything you think might help us
Enter the letters you see above
ASA's National Program of the Year, 2005
Clay White (770)393-3939

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