MUSICAL SPEECH CLASS SIGN-UP

Parent/Guardian Name *

First

Last

Email *

Phone Number *

Child's Name *

Date of Birth *

Child's Age *

Do you have any specific concerns regarding your child's speech and language development? *

What is your goal for this class? *

I understand that no make ups will be provided for classes missed. I understand that Musical Speech classes are classes and not group therapy, therefore I will not be provided with a superbill for insurance reimbursement. I understand that there will be no refunds after July 10th, except under the following conditions: if the group does not have a minimum of four children. *

I Agree

INDEMNIFICATION AND WAIVER I hereby assume all risk and agree to accept full responsibility and liability for any damages or injuries I or my dependent may cause or suffer arising out of participation in the above-referenced activity or event sponsored by Northshore Pediatric Speech and Language Therapy, including any such damages or injuries occurring during, resulting from, or related to any travel to or from the activity or event or any travel arrangements or transportation which may be provided for or as a part of the activity or event. I hereby agree to be fully liable for and hereby agree to waive and release Northshore Pediatric Speech and Language Therapy, its employees and contractors from any and all injuries, costs, damages, causes of action, claims and any consequential and incidental damages arising out of or resulting from any injury, death, or damage to property which I or my dependent may sustain or cause as a result of my participation in the above-referenced activity or event sponsored by Northshore Pediatric Speech and Language Therapy, including any such injuries, costs, damages, causes of action, claims and any consequential and incidental damages occurring during, resulting from, or related to any travel to or from the event or any travel arrangement or transportation provided as a part of the activity or event. I further agree to indemnify, reimburse, and forever hold harmless Northshore Pediatric Speech and Language Therapy its employees, and contractors from any and all injuries, costs, damages, causes of action, claims and any consequential and incidental damages arising out of or resulting from any injury, death, or damage to property which I or my dependent may sustain or cause as a result of participation in this activity or event sponsored by Northshore Pediatric Speech and Language Therapy, including any such injuries, costs, damages, causes of action, claims and any consequential and incidental damages occurring during, resulting from, or related to any travel to or from the activity or event or any travel arrangement or transportation provided as a part of this activity or event. I am aware of the risks associated with participation in this activity or event and hereby accept and assume on behalf of myself or dependent full responsibility for any and all such risks, including, without limitation, the need to check with a physician before engaging in this activity or event, including any physical activity associated with this activity or event. I further agree that my own or dependent's own personal health insurance with or membership in shall be the primary source of health insurance coverage in the event that I or my dependent sustain an injury while participating in this activity or event sponsored by Northshore Pediatric Speech and Language Therapy . I acknowledge that I have read and voluntarily agree to the terms of this Indemnification and Waiver. If any portion of this Indemnification and Waiver shall be held invalid for any reason under the laws of the United States, Washington, or King County, those parts that are not held invalid shall continue in full force and effect. I hereby grant my permission to my dependent to participate in the above-referenced activity or event, subject to all of the above terms and conditions and information provided. I hereby agree to waive any and all claims that I may have, either directly or indirectly, against Northshore Pediatric Speech and Language Therapy, its employees, and contractors as result of any and all injuries to my dependent or damage to property of my dependent in relation to his or her participation in the activity or event sponsored by Northshore Pediatric Speech and Language Therapy, including any claims that occur during, resulting from, or related any travel to or from the event or any travel arrangements and further agree to indemnify, reimburse, and forever hold harmless Northshore Pediatric Speech and Language Therapy, it's employees, and contractors from any and all injuries, costs, damages, causes of action, claims and any consequential and incidental damages arising out of or resulting from any injury, death, or damage to property which my dependent may sustain as a result of his or her participation in this activity or event sponsored by Northshore Pediatric Speech and Language Therapy, including any such injuries, costs, damages, causes of action, claims and any consequential and incidental damages occurring during, resulting from, or related to any travel to or from the activity or event or any travel arrangements or transportation provided as a part of this activity or event. *

I Agree

I understand that I will be sent an invoice for the full class tuition of $200 via Square Invoice and payment must be received before my place in the class is guaranteed. *

I understand

Parent's e-signature *

Date/Time of Signature *

Name