Peer Model Enrollment Packet
  • General Information

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  • Gender      Present Age   
    Present Height    Present Weight      

  • 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*   

  • Primary Physician/Pediatrician * Phone Number *
    Address   *   

  • 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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  • Family Commitment

  • In order for my child to receive therapeutic services at The Bell Center, I understand and commit to the following obligations:

    1. Our family will actively support and encourage the development of all children participating in Bell Center programs, and will respect the right of families to maintain confidentially regarding their early intervention services

    2. I will actively participate and support fundraising activities that benefit The Bell Center. I understand that families are expected to participate in the Family Fundraisers. This includes Poinsettia Sale and BellRunners. Should I not participate, I understand that the cost of those tickets/items will be applied to my monthly statement.

    3. I will not bring my child to school if a contagious illness and/or fever is present in my household or has been present within the past 24 hours.  In the event that my child will be absent from the program, I will notify the team via brightwheel as soon as possible. 

    4. I understand that I am expected to attend at one informational parent meeting per year.

    5. Each day I will send with my child:
               sufficient diapers and wipes
               a change of clothes
               cup

    6. I understand that children must be brought on time and picked up on time.

    7. I understand that my child will only be released to individuals listed on our initial general information paperwork. The Bell Center will ask for an ID if they do not recognize the person picking up my child. I understand that, someone who is not listed attempts to pick up my child, The Bell Center will not release my child to that individual.

    8. In the event that my child misses four (4) consecutive therapy sessions without explanation and/or just cause as determined by The Bell Center staff, I understand that he/she will be dropped from The Bell Center. 

    9. I understand that The Bell Center will follow CDC guidelines related to Covid.
     

    10. I understand that failure to follow through on any of these items may result in my child being dropped from The Bell Center.

    11. I understand that in the event of weather-related closings, it is my responsibility to check for possible closing information on Fox 6, ABC 33/40, our social media and brightwheel.

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  • Picture and Information Release Form

  • I, (parent's name) *, hereby give The Bell Center for Early Intervention Programs and The Service Guild permission to use pictures or video of my child * (name of child) for the purposes of promoting the program of services offered by The Bell Center for Early Intervention Programs. It is agreeable to use pictures or video or video for publicity and promotion purposes in newspapers, newsletters, magazines, brochures, bulletins and other publications and electronic forms distributed by The Bell Center and The Service Guild. I understand that in signing this form, I release The Bell Center and The Service Guild of all liability in its actions under this permit.

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