Ready Readers Literacy Group

This group meets Wednesdays 5-6 at our Elmwood clinic (524 Elmwood park blvd. ). Attendance is extremely important for this group in order to make progress. We require 80% attendance to remain in the group.

Child's name*

First NameLast Name

Date of birth*

Date

Age*

Grade*

School*

Gender*

Parent/Guardian*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Please explain current difficulties your child is having with reading or any feedback from your child's teacher:*

Does your child have any diagnoses that would assist in planning for this program? (dyslexia, ADHD, autism, etc.)*

Has your child had a recent evaluation of any kind (speech, educational, psychological, etc.)? If so, what were the results?*

Does your child have a current IEP or 504 plan at school? If so, please describe some of the goals and/or accommodations your child receives.*

Does your child currently receive any therapy services or tutoring? If so, please explain.*

Are there particular letters or sounds that your child is having difficulty with?*

Does your child demonstrate the following phonological awareness skills:*

	Yes	No	Not sure
Identifying words that rhyme (ex: Which word rhymes with "bat": "hat" or "bus"?)
Identifying the number of syllables in words (ex: How many syllables are in the word "apple"?)
Identifying sounds within a word (ex: What is the first sound in the word "cat"?)

Is your child having difficulty understanding what they are reading? If yes, please describe.*

Any additional information that we need to know?

Thank you for your interest in this group! Upon entrance into the group, the Speech-Language Pathologist will complete a screening to determine your child's abilities and assist in planning for the group. The speech therapist may give recommendations for individual therapy if necessary.

Please give our Programs Administrator 1-2 business days to contact you about your submission. Thank you!

How did you hear about Therapeutic Learning Center's Ready Readers Group?*

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”) Ready Readers Program (“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, handicaps, 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.

Please Read before signing.

Signature*