Ready Set Learn Registration Form

Ready Set Learn Registration Form
WHAT IS READY SET LEARN: A 6-week group program (12 classes) led by Occupational, Physical and Speech Therapists to help develop and enhance children’s attention, social skills, self-care, language development and the endurance needed, for participation in more structured activities and instructional environments.

PURPOSE: To develop skills that will help children to be Ready for direction, Set for success and able to LEARN to their fullest potential.

WHEN: Tuesdays and Thursdays, May 23rd – June 29th from 11am-12:30pm

WHERE: Premier Pediatric Therapy Source clinic location
6715 Little River Turnpike, Ste 200 Annandale, VA 22003

COST: $1200.00/Early Bird Special - 20% off through May 15th ($960.00)

PARTICIPANT CRITERIA: Ready Set LEARN is designed for children 3-4 years of age who are slow to warm up to people, new experiences or environments and/or have had limited exposure to participating in structured group activities. Children appropriate for this class should display no self-injurious behaviors or aggressive behaviors to others such as hitting, kicking, biting, spitting or scratching.

*If you have questions regarding your child’s appropriateness for this program, we are happy to speak with you to help make that determination.

PROGRAM GOALS:

Children will:
- Participate in a structured movement and language enrichment activity
- Increase their familiarity with routines to support transitions between structured and unstructured tasks
- Receive exposure and enrichment to basic concepts targeted and necessary for school-age learning such as body awareness, joint attention, instruction sequencing, emotional regulation, and basic life/self-care skills
Parent/Caregiver will:
- Feel more confident implementing a structured activity
- Be more confident/comfortable in their child’s ability to participate in a novel, adult-facilitated program
- Learn therapeutic techniques to support their child’s participation and acquisition of skills
WHAT TO BRING:
- Comfortable clothes and supportive footwear
- A positive attitude and readiness for fun and learning!
WHAT TO EXPECT:
1. Parking: You may park on side parking lot or back of the building at Premier Pediatric Therapy Source
2. All classes build upon skills learned in previous classes. If you need to miss a class for any reason, we will do our best to work with you so that you and your child are prepared for the next class.
3. Parents/Accompanying adults are expected to remain on site for the full duration of each class
4. A parent discussion group is included and will be held once a week, led by a Licensed Therapist, while your child is participating in the group class. The purpose of this group will be to discuss what’s being learned in the program, developmental areas across childhood, share experiences as parents as well as get questions answered for supporting your child’s readiness for more structured activities and environments
5. We strongly encourage your child use the restroom before each class however, should your child need to use the restroom during the Ready Set LEARN, you will be expected to take them

Ready Set Learn Participant Waiver
Waiver & Release of Liability: PLEASE READ CAREFULLY BEFORE ACCEPTING PARTICIPATION. THIS IS A RELEASE OF LIABILITY & WAIVER OF CERTAIN LEGAL RIGHTS.
I blanks the parent/legal guardian of blank, voluntarily release and hold harmless PREMIER PEDIATRIC THERAPY SOURCE, INC.“PPTS” and it's volunteers from any and all claims, demands and causes of action whatsoever, arising out of or related to any and all claims of loss, damage, or injury, that may be sustained by the participant(s) and/or the undersigned, while engaging in the READY SET LEARN PROGRAM.
I agree to remain on site for the full duration of each Ready Set LEARN class. I further agree to abide by and follow all safety rules presented during Ready Set LEARN classes and willingly and knowingly assume for myself and the minor participant, all risk of physical/emotional upsets which may occur during any class and I agree to hold PPTS employees harmless from any and all liability arising from participation. I understand, agree, and acknowledge that there are risks inherent to any physical and/or group activity and that these activities may be of a hazardous nature.

With full understanding of the facts, I state that to the best of my knowledge I, or my child listed above, have no medical, physical, or emotional health conditions, which would hinder or prevent participation in the Ready Set LEARN Developmental Skills Camp. I also understand that this form must be signed by the adult participant and/or parent/legal guardian of a participant under 18 years of age prior to participating in Ready Set LEARN classes.

I HAVE CAREFULLY READ ALL OF THE ABOVE INFORMATION. I ACCEPT AND ACKNOWLEDGE IT WITH FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE. I UNDERSTAND THAT THE INFORMATION HEREIN WILL GOVERN MY RELATIONSHIP AND THE RELATIONSHIP OF ANY PARTICIPANTS WITH PPTS. MY ACCEPTANCE HERE SUPERSEDES ANY OTHER AGREEMENT, WRITTEN OR ORAL, THAT MAY HAVE BEEN PRESENTED TO ME WITH RESPECT TO MY RELATIONSHIP WITH PPTS.
First and Last Name of Child Participant*
Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian Name*
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Adult Participant Name(if different from above)
Adult Participant Name Signature

Clear
Date

MonthDayYear
Date

Ready Set Learn Photo Release Consent
I understand that photographs or videos may occasionally be taken during the Ready Set LEARN Developmental Skills Camp and may be used for Premier Pediatric Therapy Source (PPTS) marketing purposes to promote the Ready Set LEARN program or other services provided by PPTS, through print material, the practice website, social media, promotions, video and/or other advertising.

I understand that I can choose to not have my child photographed and it will not prevent my child from participating in the Ready Set LEARN Developmental Skills Camp.

I further understand I can revoke my authorization for the above uses at any time by sending a written notice to

Premier Pediatric Therapy Source: 6715 Little River Turnpike, Suite 200, Annandale, VA 22003.

Please initial your preference and sign below.
I grant permission and consent for my child to be photographed during Ready Set Learn and release all rights related to said photographs.
I request that photographs NOT be taken of my child during Ready Set Learn.
Name of Parent/Legal Guardian*

First NameLast Name
Child Participant Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Payment Form

Ready Set Learn For the 20% off Early Bird Discount Enter COUPON CODE: RSL23 - (Early Bird Discount Ends May 15th)

$1,200.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

To download a copy of the registration, waiver and photo release forms click the "Preview PDF" button.

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Ready Set Learn Registration Form

Emergency Contact Information

Ready Set Learn Participant Waiver

Ready Set Learn Photo Release Consent

Payment Form