Preschool Prep Program Registration Form

Preschool Prep Program Registration Form
Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *

Area Code Phone Number
Parent/Guardian *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Work Number *

Area Code Phone Number
Email *
Occupation/Employer

Emergency Contact Information-Alternate Pick-Release
Emergency Contact #1
Name *

First Name Last Name
Mobile Phone Number *

Area Code Phone Number
Work Phone

Area Code Phone Number
Email *
example@example.com
Relation to child *
Emergency Contact #2
Name *

First Name Last Name
Mobile Phone Number *

Area Code Phone Number
Work Phone

Area Code Phone Number
Email *
example@example.com
Relation to child *
Please list those people who are permitted to pick up your child *
Your child will not be released to anyone that is not listed above. Please contact us in advance for occasions where an individual not listed will be picking up your child.

Medical Release Information
Primary Physician *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Hospital Preference *
Please list any medical conditions, including any that requires maintenance medication (i.e. Diabetes, Asthma, Seizures). If medication needs to be administered while your child is at TLC, you will need to come to TLC to administer medication. No staff is allowed to administer medication. *
Is your child presently being treated for an injury or illness, or taking any form of medication for any reason? If your answer is yes, please explain: *
Is your child allergic to any type of food or medication? *
If yes, please explain:
Does your child have a diagnosis? If so, please explain: *
Does your child require any accommodations? *
If yes, please explain:
Does your child require a shadow, paraprofessional or ABA professional at school? If yes, you are responsible for providing the shadow, paraprofessional, or ABA professional so they can attend with your child. *
Is your child potty-trained? *
If no, please explain current training status:
Does your child require a special diet? *
If yes, please explain:
The purpose of the above listed information is to ensure that medical personnel have details of any medical condition which may intefere with or alter treatment.
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.
Parent's /Guardian Initials *
Daycare Information
What daycare/preschool does your child attend? *
What does your child's daycare/preschool have planned for your child's learning model? (ex. Distance, Hybrid or another model) *
What is the start date of your child's daycare/preschool? *
Please tell us about your child's typical daycare/preschool day and any assistance or accommodations he/she may need to be successful. *
IEP Services ~ Does your child receive therapy services? Are you interested in your child receiving individual therapy while they are at TLC? *
What are your goals for your child's Preschool Prep at TLC? What would you like TLC to assist with as far as your child's learning? Please rank your priorities for your child starting with your top priority. *
How you heard about Therapeutic Learning Center Programs? *

Website Flyer Word of mouth School Facebook/Instagram
Terms of Agreement
The Therapeutic Learning Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded unless a child is unable to participate due to an accident or illness per physician orders.
Waiver

THERAPEUTIC LEARNING CENTER, LLC

PARENT

Permission Slip, Waiver of Liability, Indemnification, Medical Agreement

and Grant of Rights

Permission Slip

I, the parent/legal guardian of this participant, hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Preschool Prep Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgment of voluntary consent to allow my child to participate in this Program.

Waiver of Liability

My signature below indicates my understanding of the details of the Program. On behalf of my child, I voluntarily agree to accept any and all risks associated with their participation in the Program. On behalf of my child, I agree to forever indemnify, hold harmless, waive, and release TLC, its respective officers, members, employees, insurers, and representatives (“TLC Group”) thereof, from liability for any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have on my behalf or on behalf of my child, known or unknown, directly or indirectly, for any losses, damages, or injuries, including death, arising from, but not limited to, negligence, omissions, or fault, by or on behalf of TLC.

Indemnification

I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the Program.

Medical Agreement

If the participant has any special medical problems, allergies, dietary needs, disability, special prescriptions, etc., please list (and use additional sheets if necessary) I have explained them in the registration form above.

In case of an emergency, all attempts to reach me should be made to the telephone number(s) stated above on the registration form.

If any emergency medical procedures or treatments are required during the Program, I hereby consent to the staff of TLC’s Program, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter. My signature below also indicates that my child is in adequate physical condition to participate in the Program.

GRANT OF RIGHTS

I, Parent/Legal Guardian, grant TLC the right and license to use my child’s liken, photographs and other attributes (collectively, “Approved Attributes”) to promote and advertise TLC’s services in the media including TV, radio, print advertising, point-of-sale materials, promotional materials, grassroots marketing efforts, public relations efforts and the Internet (to include but not be limited to web banners, blogs, and social networking sites).

Declaration

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, WAIVER OF LIABILITY, INDEMNIFICATION, MEDICAL AGREEMENT, and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

Severability

The Undersigned expressly agrees that the foregoing Release, Waiver and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall notwithstanding, continue in full legal force and effect.

READ BEFORE SIGNING
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Printed Name of Parent/Guardian *
I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and or webspace: *
Check the day and time you wish to enroll your child. Please contact the office to provide a payment method or use the payment options below.
Please tell us the days of the week that you would like to send your child. *
Should be Empty:

Preschool Prep Program Registration Form

Daycare Information