Social Skills Registration Form

Social Skills Registration Form
Please use this form to register your child for our social skills groups. We appreciate any information you can provide to assist with planning and preparation for our groups. These groups are ongoing and participation on a weekly basis is expected. If you are unable to attend the group one week, please contact our office to let us know. If your child does not attend for 2 consecutive weeks, we will remove your child from the list. Thank you and we look forward to working with your child!
Name *

First Name Last Name
Date of birth *

Month Day Year
Date
Gender *
Age *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *

Area Code Phone Number
School Name
Parent/Guardian *

First Name Last Name
Phone Contact Number *

Area Code Phone Number
Email *
Social Skills Groups for Ages 3-5 year olds (check one group)

Mondays 5-6 pm
Social Skills Groups for Ages 5-7 year olds (check one group)

Tuesdays 4:15 - 5:15pm
Social Skills Groups for Ages 7-10 year olds

Tuesdays 4:00 - 5:00pm Wednesdays 5:00 - 6:00pm
Social Skills Groups for Ages 11-15 year olds

Mondays 5:00 - 6:00pm

Medical Release Information
Child's pediatrician: *
Pediatrician's phone: *
Is your child allergic to any type of food or medication? *
If yes, please explain:
Does your child have a diagnosis that will assist with program planning? If so, please explain: *
What are your main concerns related to your child's social skills? *
Does your child require special accommodations? *
Is your child potty trained? *
If no, please explain:
The purpose of the above listed information is to ensure that medical personnel have details of any medical condition which may intefere with or alter treatment.

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.
Parent's /Guardian Initials *
How did you hear about Therapeutic Learning Center's Social Skills Groups?

Website Flyer Word of mouth School Facebook/Instagram
Terms and Conditions

The Therapeutic Learning Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded unless a child is unable to participate due to an accident or illness per physician orders.

Waiver

THERAPEUTIC LEARNING CENTER, LLC - PARENT

Permission Slip, Waiver of Liability, Indemnification, Medical Agreement and Grant of Rights

Permission Slip

I, the parent/legal guardian of this participant, hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Social Skills Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this Program.

Waiver of Liability

My signature below indicates my understanding of the details of the Program. On behalf of my child, I voluntarily agree to accept any and all risks associated with their participation in the Program. On behalf of my child, I agree to forever indemnify, hold harmless, waive, and release TLC, its respective officers, members, employees, insurers, and representatives (“TLC Group”) thereof, from liability for any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have on my behalf or on behalf of my child, known or unknown, directly or indirectly, for any losses, damages, or injuries, including death, arising from, but not limited to, negligence, omissions, or fault, by or on behalf of TLC.

Indemnification

I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the Program.

Medical Agreement

If the participant has any special medical problems, allergies, dietary needs, handicap, special prescriptions, etc., please list (and use additional sheets if necessary) I have explained them in the registration form above.

In case of an emergency, all attempts to reach me should be made to the telephone number(s) stated above on the registration form.

If any emergency medical procedures or treatments are required during the Program, I hereby consent to the staff of TLC’s Program, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter. My signature below also indicates that my child is in adequate physical condition to participate in the Program.

Grant of Rights

I, Parent/Legal Guardian, grant TLC the right and license to use my child’s liken, photographs and other attributes (collectively, “Approved Attributes”) to promote and advertise TLC’s services in the media including TV, radio, print advertising, point-of-sale materials, promotional materials, grass roots marketing efforts, public relations efforts and the Internet (to include but not be limited to web banners, blogs and social networking sites).

Declaration

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, WAIVER OF LIABILITY, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

Severability

The Undersigned expressly agrees that the foregoing Release, Waiver and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.

READ BEFORE SIGNING
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Printed Name of Parent/Guardian *
Should be Empty: