Social Skills and Dinner Club Sign-up

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Child's Name *

Does your child have a medical diagnosis? If yes, please list diagnosis. *

Does your child have allergies or take any medications? *

Please describe how your child relates to other children. Do they initiate play with others? *

Please explain what your goals are for your child during group therapy. *

Does your child get easily overwhelmed? If so, please explain. *

What activities hold your child's attention the longest? *

What activities hold your child's attention the least amount of time? *

Does your child avoid any play activities? *

Has your child ever received speech therapy or group services? If so, with whom and for how long? *

How would you describe your child? (i.e. Overactive, shy, friendly, defiant, etc.) *

How does your child respond to facial expressions? For example, can he/she tell you are upset by just looking at your face? *

Is your child competitive? Please explain. *

How does your child respond to compromise and verbal discussions? *

How does your child respond to sudden changes in environment or schedule? *

Is your child able to problem solve when something unexpected happens? Please explain. *

Anything else we should know? *

I understand that no make ups will be provided for classes missed. I understand that Social Skills Groups 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 March 1, except under the following conditions: my child is not offered placement in a social skills group or if that group does not have a minimum of two 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 my child must attend the screening and introduction session from 5:30-6pm on Tuesday, March 6th.

I agree

Parent's E-signature *

Date / Time *

Date

Time

Multiple Items *

Pay in full
Payment Plan

Payment Plan: $250 due at registration and credit card on file will be automatically charged $170 on the first of the remaining 3 months.

We will provide you with a full refund until March 6th. After March 6th, 2018, refunds will only be provided if we are unable to match your child with an appropriate group. Should your child not be placed in a group this session or a group not have two children in it, all fees will be returned to you.

I understand and agree