Foundation Subscription Form

SUBSCRIPTION SERVICES

Solid Ground Foundation for Behavioral Services
Solid Ground Foundation for Behavioral Services provides ABA Therapy services to youth ages 3y to 14y, including children with disabilities and English learners.

Monthly membership-based services are availablefor learners without qualifying diagnoses or commercial insurance.

Contact us directly for more information at 708-290-9019 before enrolling.

Location: 13136 S Western Ave, Blue Island, Illinois

Early Learner Enrichment Time (3y-8y): Tuesday, Wednesday, and/or Thursday from 11a-5p

After School Enrichment Time (5y-14y): Tuesday, Wednesday, and/or Thursday from 3p-6p
Member Information

Please submit one form per member
Learner Name*

First NameLast Name
MaleFemaleNon-Binary
Current School
Current Grade*
Date of Birth*

MonthDayYear
Age:*
Allergies or Other Medical Conditions:*

PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
YesNo
Emergency Contact (other than the parent above)

In the case that we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent above).
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number

Photographic & Media Consent
You are being asked to give consent for the collection and use of your child’s personal images by photography or video recording. If you give consent, you are acknowledging that these images may be used on the Solid Ground Foundation for Behavioral Services website, newsletters, and publications as well as distributed to members or used for promotion in the future. No personal information, such as names, will be used in any publications unless express consent is given.
I HEREBY GIVE consent to the collection and use of my child’s personal images by photography or video recording.I DO NOT give consent for Solid Ground Foundation for Behavioral Services to collect and use my child’s personal images by photography or video recording.

Parent Involvement
Solid Ground Foundation for Behavioral Services is family centered and works collaboratively with all "village members" to ensure the needs of our members are met.

In efforts for us to maximize individualized service outcomes for young "souls" we require bi-monthly parent involvment.

By enrolling your child, you HEREBY agree to participate in monthly parent coaching and/or family guidance sessions.
I HEREBY agree to participate in monthly parent involvement sessions or seminars

Consent to Participate
I hereby consent to the participation of my child in all Foundation activities including skill building across areas of academics, social skills, leisure recreation, team games, individudal crafts, snack times, meals, and/OR crisis management.

I, the Parent or Guardian named below, authorize Solid Ground personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above.

I, the Parent or Guardian named below, undertake and agree to indemnify and hold blameless Solid Ground Foundation for Behavioral Services, its Personnel, its Leaders, and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the therapeutic activities, as well as of any medical treatment authorized by the supervising individuals representing Solid Ground.

This consent and authorization is effective when participating in or traveling with Soid Ground.

I have read, understood, and agree with above.
Name*
Signature*

Solid Ground Subscription Form

Services & Programs

My Products

Early Learner ABA Therapy (1-DAY)$489.36

Members attend 1x per week (Tuesday through Friday) 11A-2P. Membership fees are electronically deducted monthly on the 30th day of each month so long as your child is actively enrolled. Email us to disenroll. Select day(s) of attendance in STRIPE. NO DATE CHANGES ARE ALLOWED WITHOUT PRIOR APPROVAL. NO MAKE UP DAYS ALLOWED.

Early Learner ABA Therapy (2-DAYS)$978.72

Members attend 2x per week (Tuesday through Friday). 11A-2P. Membership fees will be electronically deducted monthly on the 28th day of each month so long as your child is actively enrolled. Email us to disenroll. Select day(s) of attendance in STRIPE. NO MAKE UP DAYS ARE ALLOWED

Early Learner ABA Therapy (3-DAYS)$1,468.08

Members attend 3x per week (Tuesday through Friday) 11A-2P. Membership fees will be electronically deducted monthly on the 28th day of each month so long as your child is actively enrolled. Email us to disenroll. Select day(s) of attendance in STRIPE. NO MAKE UP DAYS ARE ALLOWED

AFTER SCHOOL ABA Therapy (1-DAY)$489.36

Members attend up to 1x per week from 3p-6p on Tuesday, Wednesday, OR Thursday. Membership fees are electronically deducted monthly on the 28th day of each month so long as your child is actively enrolled. Email us to disenroll. Select day(s) of attendance in STRIPE. NO MAKE UP DAYS ARE ALLOWED.

AFTER SCHOOL ABA Therapy (2-DAYS) $978.72

Members attend up to 2x per week from 3p-6p on Tuesday, Wednesday, OR Thursday. Membership fees are electronically deducted monthly on the 28th day of each month so long as your child is actively enrolled. Email us to disenroll. Select day(s) of attendance in STRIPE. NO MAKE UP DAYS ARE ALLOWED.

AFTER SCHOOL Life Enrichment (3-DAYS) $1,468.08

Members attend up to 3x per week from 3p-6p on Tuesday, Wednesday, OR Thursday. Membership fees are electronically deducted monthly on the 15th of each month so long as your child is actively enrolled. Email us to disenroll. Select day(s) of attendance in STRIPE. NO MAKE UP DAYS ARE ALLOWED.

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SUBSCRIPTION SERVICES

Member Information

PARENT/GUARDIAN INFORMATION

Emergency Contact (other than the parent above)

Photographic & Media Consent

Parent Involvement

Consent to Participate

Solid Ground Subscription Form