Release Form

Please check the session(s) and program(s) you are interested in: *

The fee for each group MOTION! class is based on the number of children who attend the session. Please enquire for group, private session, and private intensive fees.

Private session length and time are subject to change based on the age and needs of the students. Additional classes may be added as required. All prices include tax and art supplies. To register please e-mail info@adaptedspiralpraxis.com or call 416-469-3569 to set up an initial meeting for assessment and discussion. Space is reserved on a first come, first served basis so please register early.

I. Personal Information

Participant's Name *

First

Last

Date of Birth *

Parent/Guardian's 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?

Person #1

Name

First

Last

Relationship

Phone

Person #2

Name

First

Last

Relationship

Phone

Additional Contact #’s such as cell phones and such can be listed below if need be.

What is the diagnosis of your child? *

Are they on any medication(s)? *

Yes
No

Please list the name(s) of the medication(s). *

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 weekly with a Support Worker)

Please help us make the program fun 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 take photographs and videotape sessions if applicable during the designated time of the program. *

Yes
No

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

Yes
No

If the above named participant will be traveling to and from Spiral Movement Center with as- sistance, 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

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. Yuji Oka and his staff from all claims arising from whatever participation in any program organized by the staff or volunteers of Spiral Movement Center. 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. Refund/Cancellation Policy

If a course is cancelled due to low enrollment, registrants will be given one week notice and refunds will be issued subsequently. No refund will be given after the first class. Please note there will be a fee of $25 assessed for any invalid or bounced checks.

A full commitment to attendance and participation is encouraged. We regret that reimbursement for missed classes cannot be offered. Please note that Spiral Movement Center reserves the right to remove a participant from the program if we deem appropriate. However, every measure will be taken to work with the participant and his/her family before this action is taken.

Spiral Movement Center Student Release Form

Follow Us