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  • General Information

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  • Gender      Present Age   
    Present Height    Present Weight      

  • Reason for Referral/Diagnosis (if known)*


  • The information below refers to            
    Do both parents live in the home?         

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  • Employer   *  
    Work Phone*   
    Cell Phone   *   
    Email Address*   

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  • Employer   *   
    Work Phone*   
    Cell Phone   *  
    Email Address*   

  • Sibling
    Date of Birth
    Name of School      

  • Sibling
    Date of Birth
    Name of School      

  • Primary Physician/Pediatrician * Phone Number *
    Address   *   

  • Our goal at The Bell Center is to ensure the health of our participants.  Vaccinations are an important tool to prevent dangerous illnesses in children.  To best use vaccines as a tool and for the safety of all we serve, we require participants to receive all state required vaccinations for school entrance per the American Academy of Pediatrics’ recommended schedule.

  • Maternal and Neonatal History

  • Length of pregnancy (weeks) Duration of labor
    Where was the child born?         

  • Birth weight * Birth length *

  • General Medical Information

  • Developmental Profile

    Fill in the approximate age your child began to:
  • Roll Over
    Drink from cup/straw
    Have full head control     
    Reach for toys & hold them      
    Sit alone      
    Potty Train      
    Crawl      
    Show interest in books      
    Pull to stand     
    Recognize self in mirror    
    Walk holding furniture    
    Look at toys, not just people   
    Walk alone       
    Show purposeful interest in toys   
    Give up breast/bottle 
    Engage in peek-a-boo     
    Finger feed       
    Clap hands    
    Begin baby food     
    Imitate gestures    
    Begin table food       
    Roll a ball & return in play       
    Use a spoon to eat       
    Play finger games         
         

  • Authorization to Disclose Information

    Medical
  • Child's Full Name *
    I, (parent name) *, hereby authorize the disclosure of information for the purpose of early intervention services from The Bell Center for Early Intervention Programs to the following medical professionals and/or others as indicated.

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  • Authorization to Disclose Information

    Early Intervention/Public School System
  • Child's Full Name *
    I, (parent name) *, hereby authorize the disclosure of information for the purpose of early intervention services from The Bell Center for Early Intervention Programs to the following medical professionals and/or others as indicated.

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  • Full Release and Waiver of Liability

  • In consideration for accepting the undersigned child into The Bell Center for Early Intervention Programs, and the providing of professional services to the undersigned child by the same, I, as the parent and legal guardian of the undersigned child, do hereby fully release and discharge, for myself, my heirs, legal representatives, and assigns, the following: The Bell Center for Early Intervention Programs, The Service Guild of Birmingham, Inc., and their agents, servants, volunteers, and employees from any and all legal liability or claims for money damages, compensation or indemnification, arising from, and by reason of, any and all known and unknown illness, injuries or damages, that may be suffered by the undersigned child due to or resulting from his/her participation or attendance in any activities or professional services provided by The Bell Center for Early Intervention Programs. This release incorporates as it fully set forth herein the Alabama "Volunteer Service Act." I understand that The Bell Center is not responsible for determining when medical procedures are needed for my child nor for the administration of any procedure nor the upkeep of any medical equipment. 

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  • Program Fee Responsibilities

  • The Bell Center requires several fees each year. Following is a list of these fees and when they are due. 

    Evaluation Fee - $245.00

    This fee is due at the time of the evaluation. I understand that the professional staff will evaluate my child using the Revised Hawaii Early Learning Profile before he/she begins therapy at TBC. 

    I also understand that my child will be re-evaluated each year that he/she participates in a Bell Center Program, and on his/her entry date anniversary the existing re-evaluation fee applies. 

    Supply Fee For My Friends $100.00 - All other programs Supply Fee $85.00

    I understand that a $75.00/$100.00 supply fee is due each year that my child participates in TBC programs. This supply fee is due September 1st. 

    If my child enters the program between January 1st and March 31st, this fee is $37.50/$50.00. (There is no supply fee charged for the program year if enrolled on April 1 or after.)

    Registration Fee $50.00

    Each year my child registers for a Bell Center program a registration fee applies with typically occurs in April.

    Program Fees

    Monthly Program Fees are duby the 15th of each month. The current fee schedule is provided on out website. (www.thebellcenter.org)

    A late fee of $25 will apply to unpaid balances. I understand that balances due over 30 days will result in my child not receiving services until the balance is cleared. 

    *The Bell Center recognizes that each family comes to us with unique financial circumstances. Financial assistance is available for tuition and applications are available by contacting Jeannie Colquett, Executive Director, at jcolquett@thebellcenter.org or 205-879-3417. 

    If needed, a monthly payment plan for evaluation fees and supply fees can be arranged with Janet Wilson, bookkeeper, at jwilson@thebellcenter.org. 

     

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  • Therapy Picture Release

  • I hereby give my permission to The Bell Center for Early Intervention Programs to use a picture or pictures of (child's name) * for therapy purposes as part of services offered by The Bell Center for Early Intervention Programs. This picture will not be used for marketing.

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