International Intensive Speech Therapy Program

    (*) marks fields that are mandatory.


    International Intensive Speech Therapy Program

    Country of origin (*):

    Participant (child):

    Child Full Name (*)

    Child Birthdate (*)

    Medical Diagnosis (*)

    Child's Difficulties (*)

    Communication Level (*)

    Parent or legal guardian contact information:

    Full Name (*)

    Email Address (*)

    Phone Number (*)

    I hereby authorize the processing of my personal data for the purposes of facilitating the program and conducting post-program quality assessments, as well as for other purposes as outlined in the Privacy Policy. Full disclosure regarding the processing of your data is available on the Information Obligation page.

    In the event of participation in the program, I hereby grant consent for the use of my image recorded during the program, in accordance with the provisions of the Consent for Image Publication.