West Coast Centre for Learning - Secret Agent Society Spring (In-Person) Registration_ KGH_ April 13

A grade 3 level of reading is required to participate in the program.

Please only choose an installment plan if you do not have access to Autism/School funding and are paying by credit card

Secret Agent Society Spring (In-Person) Class - CANCELLED

* No class on May 18

3/10 upcoming

Monday 4:00 PM - 5:30 PM

April 13, 2026, April 20, 2026, April 27, 2026, May 4, 2026, May 11, 2026, May 25, 2026, June 1, 2026, June 8, 2026, June 15, 2026, June 22, 2026

$3,195

4 spots left

King George Hub

Register *

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Participant

First name *

Last name *

Gender *

Date of birth *

Minimum age 7 years 9 months, maximum age less than 13 years.

Grade *

Allergies *

No known allergies Tree nuts Eggs Seafood Peanuts Insect stings (e.g. bees, wasps)

Other

Important medical information * Please list any important information we may need to know.

Parent/Guardian

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You will receive your receipt by email.

Relationship

First name *

Last name *

Email *

Mobile *

Address *

City *

Country *

State/Province *

Zip/Postal code *

Other phone (home or work)

Other Parent/Guardian (Optional)

Relationship

First name

Last name

Email

Mobile

Address

City

Country

State/Province

Zip/Postal code

Other phone

Current marital status of biological parents *

Married Separated Divorced Single

Other

Where does the child reside? *

Apart from you (the applicant), is there another caregiver that will be participating in the program? * * *

Yes No

If yes, please list their name and relationship here

Please describe common situations where your child might feel anxious, angry or frustrated. *

Are there any changes that occur in your child's behaviour when they feel anxious, angry or frustrated? *

i.e. changes in body posture, voice, tone, muscle tension, changes in facial expression...

Yes No

If yes, please explain

Has your child received therapy or support to cope with their emotions, social skills or ability to get along with others? *

Yes No

If yes, please describe

Has your child undergone a Psych Ed Assessment in the past 2 years? *

Yes No Currently undergoing assessment

Upload Current Psych-Ed Assessment here

If you answered "yes" to the above question, we would find it helpful if you could share the results of the assessment report with us. All files are kept strictly confidential and all staff are bound by a confidentiality agreement.

Name of School Attending *

Name of Child's Teacher

First name *

Last name *

Email *

Other phone

Can your child read at a Grade 3 level or above? *

Yes No

Does your child receive any additional assistance at school? i.e. Learning Support, on an IEP? *

Yes No

Does your child have access to a device with internet access that they can use for the program? i.e. tablet or laptop *

Yes No

Is English your child's first language? *

Yes No

Please list any other language(s) is spoken in the home?

How would you rate how well your child speaks and understands English? *

Very Well Well Reasonably Well Poorly Very Poorly

What hobbies or interests does your child currently have? *

Is your child is experiencing any problems making friends, problems choosing the right friends, anxiety, anger, impulse control, difficulty adjusting to changes in routine? *

Yes No

If yes, please describe

Parental Consent to Participate in the Program

I hereby declare that I am the parent or legal guardian of the above-named child and that the information I have given is accurate.

I am aware of the aims and structure of the program. I have had the opportunity to ask any questions arising from the information provided and/or will seek out answers so that questions will be answered to my satisfaction. The information that I provide will be kept confidential.

I have read and accept the above, and I give consent for my child to participate in the Secret Agent Society Small Group Program *

How did you hear about us? *

Professional (Pediatrician, General Practitioner, Psychologist, Counsellor) Internet Search Act Community Training Family / Friend Social Media Other

If by a Professional/Family/Friend, please list their name below. If other, please specify.

Would you like to receive our newsletter with helpful parenting tips, program information, and special offers. (You can unsubscribe at any time) *

Yes please! No thanks

Will you be accessing funding to pay for the program? *

Autism Funding School Funding Bill me privately Other

If school or other funding, please list below.

I consent to having photographs and work samples of my child/ren to be used by West Coast Centre for Learning in promotional material. *

Yes No

Please list any questions, comments or concerns that you may have, if any:

Electronic signature*

Please sign your name inside the box

Thank you for completing our Secret Agent Society Registration Form.

Once you click “Continue,” you will be directed to our secure payment page. Please note that a $50 non-refundable intake interview fee will be applied at checkout. If you choose to move forward with the program, this fee will be credited toward the total program cost.

If you are accessing funding for payment, please follow the instructions below.

Please select "Autism/School/Other Funding" on the payment page, confirm which method of funding you will be using, then click the "I Confirm" button.

Thank you for choosing West Coast Centre for Learning, we look forward to connecting with you. If you require immediate assistance, please feel free to contact us: info@wccl.ca or (778) 839-5515

By submitting this form, you consent to West Coast Centre for Learning collecting and using your information to respond to your inquiry. For details on how your data is stored and protected, please review our Privacy Policy.