SOCIAL SKILLS 23-24

SOCIAL SKILLS 23-24

REGISTRATION FORM
Our Social Skills Programs are held as follows:

PRESCHOOL | 15h00 - 16h00 on Tuesdays

SCHOOL AGED | 16h30 - 18h00 on Mondays

TWEENS| 16h30 - 18h00 on Mondays or Tuesdays

CONNECT CLUB| 16h30 - 18h00 on Thursdays

- Parent members have a 10% discount rate. Email us at info@allspecialkids.org in case you need to receive it again.
I am:*

registering my son/daughter for a trial sessionregistering for a Term for the fist timere-registering my child for the upcoming term (all pertinent information already provided)

Please indicate which Term your son/daughter will join us:*

Preschool - Term 211 sessions

605.00CHF

Preschool - Term 310 sessions

550.00CHF

School aged and Tweens - Term 2 - Mondays11 sessions

807.00CHF

Tweens - Term 2 - Tuesdays11 sessions

807.00CHF

School aged and Tweens - Term 3 - Mondays10 sessions

733.00CHF

Tweens - Term 3 - Tuesdays10 sessions

733.00CHF

Connect Club - Term 211 sessions

807.00CHF

Connect Club - Term 310 sessions

733.00CHF

Enter coupon

Total

0.00CHF

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

GENERAL QUESTIONNAIRE
Name of Child*

First NameLast Name
Date of birth*

MonthDayYear
Date
Please upload a copy of your child's id card*

Cancelof
Please upload a copy of your child's insurance card*

Cancelof
If applicable, please attached a copy of your son/daughter’s most recent educational report

Cancelof
If applicable, please attached a copy of your son/daughter’s most recent psychological assessment

Cancelof
(If appropriate) I have attached a copy of my son/daughter’s most recent :

Educational report
Psychological assessment

The provision of reports allows us to individualise goals. All shared information is kept in strict confidence.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name of Parent/Guardian

First NameLast Name
Parent/Guardian email address*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Emergency Contact Details*

Same as contact informationOther

SOCIAL SKILLS GOALS
The ASK Social Skills Program aims to provide a fruitful and enriching environment for all children and we welcome you to provide us with specific social skills goals you may have for your child.

For example:

Goal: I would like my child to be more confident in approaching others

Current capabilities/situation: S/he is shy and do not like speaking to other children
Goal 1*
Challenges to achieving this goal*
Goal 2*
Challenges to achieving this goal*
Goal 3*
Challenges to achieving this goal*

GENERAL BACKGROUND
Mother tongue language (s)*
Other spoken/written language(s)*
Fluency of spoken/written languages*
CLINICAL BACKGROUND
Diagnoses (if any) *
Intellectual functioning *
Child’s communication level. Please list any communication aids/ supports your child uses.*
Childs’ strengths (please list any skills or special interests your child may)*
Child’s toileting routine Child’s dressing routine Child’s feeding routine (self-feed, etc.) *

CHILD INFORMATION
Child’s interests and likes:*
Child’s dislikes:*
Any sensory issues/triggers we should be aware of?*
Does your child have difficulty coping with any particular situations?*
Does your child ever engage in any behaviors of concern?*
Are there any triggers for these behaviors of concern that we should be aware of? *
What strategies work well with your child?*

MEDICAL INFORMATION
For the safety of the children and our team, we ask that you fill in this form as honestly and completely as possible. We will use the information to provide the best nurturing environment for your child.
Any know medical condition (s)*
Known learning differences diagnosis (if any): *
Medication(s) currently taking (if any): *
Known side effects of any medication(s) taken (if any):*
Please indicate if the child may suffer from seizures (frequency)*
Known triggers to seizures:*
Is there any other information which we should know? Kindly please describe/tell us in the space below:*

TERMS AND CONDITIONS
Parents and/or clients will be responsible to check with their insurance company to determine if the Sessions are covered under their terms and conditions.

ASK will not be able to offer refunds for sessions which are not attended.

Any exceptional, additional services that do not fall within the package (e.g., phone calls to professionals; school network meetings and others) will be billed individually.

In case your child will be late or not attending a session, please notify the office: 022 788 2102 or socialskills@allspecialkids.org

Privacy Notice

Our associaton collects personal data during the registration process. We use the data to design your child’s program. Your data will not be shared and it will be securely stored as per the New Federal Act on Data Protection (nFADP) guidelines.

PERMISSION TO USE PHOTOS & IMAGES
ASK-All Special Kids may wish to use photographs and images from the programs undertaken as part of this collaboration. Any such images and photographs would highlight the participants either demonstrating learning techniques or participating in the ASK programs.

In accordance with ASK policy, the names of individual participants will not be released with photographs. This release form applies only to any educational publications and promotional materials published after 15 October 2012. I hereby authorise ASK to publish the photographs taken of me and/or the undersigned program participant, for use on ASK’s website and in any printed educational publications and/or general media releases.

I {nameOf6} release ASK from any expectation of confidentiality for the undersigned program participant and myself. I attest that I am the parent or legal guardian of the participant mentioned below and that I have the authority to authorise ASK to use their photographs and images. This release is valid from the date of signature until written notice is received from the parent/guardian revoking this Authorisation.

I acknowledge that participation in publications and websites produced by ASK is voluntary, and neither the participant nor I will receive any financial compensation. I further agree that participation in any educational publications and website produced by ASK confers no rights of ownership whatsoever. I release ASK its owners, partners, volunteers, and employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned individual.
I agreeI do not agree
{nameOf}

{dateOf}
{nameOf6}
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

SOCIAL SKILLS 23-24

GENERAL QUESTIONNAIRE

SOCIAL SKILLS GOALS

GENERAL BACKGROUND

CLINICAL BACKGROUND

CHILD INFORMATION

MEDICAL INFORMATION

TERMS AND CONDITIONS

PERMISSION TO USE PHOTOS & IMAGES