Adapted Spiral Praxis Permission Form


Welcome to the ASP Intensive—we hope that your stay with us will be enjoyable and transformative for your child. We request that you fill out the registration form below which contains important information that we’ll need for your stay here. Please note that video documentation is an important part of the therapy process here and if you have any questions or concerns about filming, please don’t hesitate to contact us. Thank you for your interest in our program 🙌

I. Personal Information

Participant's Name:

Date of Birth:

Parent/Guardian Name:

Email:

Address:

Phone:

Participant's Health Card #:

Who can be contacted should an emergency arise?

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Additional contact #s such as cell phones can be listed below:

What is the diagnosis of your child?:

Are they on any medication?:

What are the names of the medications?:

Has your child ever been physically violent (hitting, kicking, scratching, etc.)?:

Please describe the causes and how they best calm down.:

Are there any special medical concerns (e.g., seizures, medications, food allergies, other?):

Does the participant need assistance with toileting or one-on-one support?:

Please ensure to arrange that s/he attends our program with a Support Worker.

Please help us optimize your stay at our studio by describing the assistance you/your child needs:

II. Photo/Video Consent and Pick-Up/Drop-Off Information

I am aware and give consent for Spiral Movement Center to receive and view videos of my child for the purpose of conducting a remote assessment, if needed.:

Will the above named participant be traveling to and from Spiral Movement Center alone?:

Please list the names of those individuals who will be assisting him/her with transit for security purposes.

Name:

Phone:

Name:

Phone:

What will the arrangements be for pickup and dropoff?:

III. Participant Release Form

I accept responsibility for my child's own medical coverage. I hereby give permission for staff/ volunteers of Spiral Movement Center, to arrange for any emergency medical care including hospitalization and transportation if necessary, and agree to pay for all expenses and cost incurred thereby. If emergency medical care is required, attempts will be made to contact emergency contact person(s) shown above. I agree to release and Indemnify and save harmless Spiral Movement Center, c.o.b. Stephanie Gottlob and Yuji Oka and their staff from all claims arising from whatever participation in any program organized by the staff or volunteers of Spiral Movement Center by any cause whatsoever. Please note that this form with its legal consents and liabilities remains in effect from the date it is signed and will apply to any future Spiral Movement Center programs that the above named participant is registered in unless advised otherwise in writing. I, the undersigned, have read and fully understand the "Participant's Release Form".

IV. Refunds/Cancellation Policy

Due to the logistical requirements necessary for children’s intensives, we require that payment be provided well in advance of your arrival. All intensives are scheduled on a first-come, first-served basis. In the event of a cancellation, we will offer a full refund up to one month prior to the scheduled intensive, and a 50% refund up to two weeks prior. We will not be able to provide refunds after this period.

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Document name: Adapted Spiral Praxis Permission Form
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June 26, 2021 11:22 pm EDTAdapted Spiral Praxis Permission Form Uploaded by Yuji Oka - info@adaptedspiralpraxis.com IP 184.147.112.26
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