Instructions: PRINT this page, FILL out and FAX or MAIL to the number or address below.
An Application Packet will be sent to you through traditional mail.

John Tracy Clinic
Parent Request Form

My Son Daughter___________________________ is _______years/months old.
(Name of child)
(age of child)
 
It was suggested by: __________________________________________ that I
enroll in your Correspondence Course for Parents of:
Part A - Babies ( ages 0 to 22 months)
Part B- Preschoolers (ages 22 months to 5 years)
Deaf-Blind
 
I would also like to receive information about your 3-week Summer Sessions (held in English only and the child must be between the ages of 2 and 4 at the time of the session)
 
Name of parents _______________________________
Email _____________________________________________
Address __________________________________________
(City and State) ___________________________________
(Zip Code) _____________________________________
(Country) ____________________________________________
 
Please mail this form to:
You may also choose to contact us at:
John Tracy Clinic Telephone: 1(213)748-5481
Correspondence Education Department 1(800)522-4582
806 West Adams Boulevard Fax: 1(213)749-1651
Los Angeles, CA 90007-2505. USA

NOTE: For your records, please make a note of our address before mailing this form to John Tracy Clinic