ASP 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 *

First

Last

Date of Birth *

Parent/Guardian Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Participant's Health Card #

Who can be contacted should an emergency arise?

Name

First

Last

Relationship

Phone

Name

First

Last

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? *

Yes
No

What are the names of the medications? *

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

Yes
No

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? *

Yes
No

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. *

Yes
No

Videos are required for remote assessment—these videos are completely confidential and will be used to please use the free service WeTransfer to send large video files to us. You can begin by pressing the WeTransfer button below. If you need additional guidance, please watch our tutorial on transferring videos. Any other files you need to send to us, such as photos or important documents, can also be sent via WeTransfer.

Tutorial: How to Transfer Large Videos

I am aware and give consent for Spiral Movement Center to take photographs and videotape sessions if applicable during the designated time of the program. (copy) *

Yes
No

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

Yes
No

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

Name

First

Last

Phone

Name

First

Last

Phone

What will the arrangements be for pickup and dropoff? *

Airport Pickup

For small families, the Spiral Movement Center offers free airport pickup on your arrival. Please note however that our vehicle is small and can only fit 2-3 passengers and their luggage. For larger groups, we recommend calling a taxi. Please view our Visitor Guide below for information on taxi services.

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.

V. Additional Needs/Requirements

If you have any additional needs or requirements, please let us know in the field below or by writing us at: info@adaptedspiralpraxis.com. We will be able to provide accommodation or adjustments depending on you and your child's specific needs.

Additional Needs/Requirements

Spiral Movement Center

Adapted Spiral Praxis Permission Form

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