TLC Day Programs Application

Name*

First NameLast Name

Date of birth*

Date

Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

School Name*

Grade*

Parent/Guardian*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Work Number*

Email*

Occupation/Employer

Emergency Contact Information-Alternate Pick-Release

Emergency Contact #1

Name*

First NameLast Name

Mobile Phone Number (Primary)*

Work Phone

Email*

example@example.com

Relation to child*

Emergency Contact #2

Name*

First NameLast Name

Mobile Phone Number (must be different than primary number above)*

Work Phone

Email*

example@example.com

Relation to child*

Please list those people who are permitted to pick up your child*

Your child will not be released to anyone that is not listed above. Please contact us in advance for occasions where an individual not listed will be picking up your child.

Medical Release Information

Insurance information

Name of Health Insurance*

Policy Number*

Primary Physician*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Hospital Preference*

Please list any medical conditions, including any that require maintenance medication (i.e. Diabetes, Asthma, Seizures). If medication needs to be administered while your child is at the program, you will need to come to the program to administer medication. No staff is allowed to administer medication. *

Is your child presently being treated for an injury or illness, or taking any form of medication for any reason? If your answer is yes, please explain:*

Is your child currently receiving therapeutic services? (i.e. occupational therapy, speech therapy, physical therapy, play therapy.) If yes, please explain. *

Does/did your child receive Early Steps services?

YesNo

Can you provide us with contact information and do we have permission to contact Early Steps?

YesNo

If you answered yes to the above questions please provide information here:

Signature

Is your child allergic to any type of food or medication?*

If yes, please explain:

Does your child require one on one assistance at their school, ABA center or daycare?*

If answered YES, please explain:*

The purpose of the below-listed information is to ensure that medical personnel have details of any medical condition which may interfere with or alter treatment.

Does your child have a diagnosis that will assist with program planning? If so, please explain:*

Is your child potty trained?*

If no, please explain current training status:

Does your child require a special diet?*

If yes, please explain:

Please provide us with helpful information if your child becomes upset, such as calm down strategies used at home or school. Also, please share any information that will be helpful for us know in order to better understand your child. (I.e. they may cry when hungry, they crawl under a table when scared, they need hugs for comfort, they need a break from a noisy environment when holding their ears, etc.)*

Please describe to us how your child communicates.*

Please tell us what activities your child enjoys engaging in.*

Does your child react strongly to unexpected or loud noises? (for example sirens, dogs barking, hair dryer) *

Does your child seem to not hear you when you call their name? (even though hearing is ok) *

Is your child bothered by bright lights or prefers bright colors/patterns?*

Does your child display the need to touch people or objects more than peers of the same age? *

Does your child pursue movement to the point where it interferes with daily routines? (for example, can't sit still, fidgets, etc.)*

Does your child put objects in their mouth? (for example, pencil, hands, etc)*

Is your child distressed by changes in plans, routines, or expectations? Please explain.*

When your child needs you to do something for him/her, which of these would they use?*

Can you and your child have a simple back and forth conversation?*

YesNo

How often can your child focus and attend to a task that is non preferred? (For example, some children don't enjoy sitting at a table to draw or when asked to clean up their toys.)*

AlwaysSometimesNever

When your child plays with toys, does he/she use them in a variety of different ways or do they have specific way they play with the toy that is non purposeful? Please explain.*

During play, does your child use words to express emotions or comment on actions/events around them?*

YesNo

What is the main goal or reason for your child to attend one of TLC's day programs?*

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.

Parent's /Guardian Initials*

Terms of Agreement

The Therapeutic Learning Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded unless a child is unable to participate due to an accident or illness per physician orders.

How did you hear about Therapeutic Learning Center Programs?*

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”) Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgement 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, handicap, 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, grass roots 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.

READ BEFORE SIGNING

Initials*

I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and or webspace:*

BEHAVIOR

We understand that children with behavioral challenges benefit from a therapeutic environment. However, if your child has aggressive tendencies or demonstrates 3 or more aggressive behaviors towards other children or staff members, they will be asked to return home without a refund. In this case, one on one therapy services may be a better fit for your child.

SUPPORT

We understand that some children benefit from having one on one support to succeed. If it is discovered that your child needs more support than our program can provide, we reserve the right to place your child to an alternative TLC program, discontinue enrollment, and/or suggest other services with outside providers to ensure the child's success.

Please acknowledge an understanding our behavior/support policy.

PLEASE INITIAL BELOW: (1) I understand that my child will need to attend a trial day to determine if he/she can be supported by TLC Day Programs. (2) If my child is not able to be adequately supported by TLC Day programs, there will be alternate recommendations for providers that can be helpful. (3) I understand that Brightwheel will be the program used to send invoices and receive payments for my child. (4) I understand that I am required to submit a credit card on file to be used if my invoices are overdue. (5) I understand that due to the nature of this program being therapeutic, my child's placement will be determined by the Programs Director.*

THERAPEUTIC LEARNING CENTER, LLC

Therapeutic Learning Center’s Therapeutic Day Programs Policies

Welcome to Therapeutic Learning Center’s therapeutic day programs. We are looking forward to a developmentally supportive, enriching and fun experience with your children. It is our philosophy at Therapeutic Learning Center that childhood should be a time full of fun, warmth, security, sharing, exploring, and discovery. Our goal is to provide a therapeutic atmosphere that encourages social, emotional, physical, and intellectual growth and development of the child.

ON THE FIRST DAY, PLEASE BRING AND LABEL EACH ITEM:

A backpack or bag with your child’s name
One complete change of clothes (shirt, shorts, socks, underwear) in a Ziploc bag
Water bottle of your choice with name on it.
Any diapering supplies including diapers and wipes.
A daily nut free lunch with a meal that does not require heating or extensive preparation.
A daily, nut-free, snack that does not require heating
Please bring one security item (lovie or blanket). Please avoid toys in their bags as they may get lost.
A labeled nap mat and blanket.
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CARPOOL INSTRUCTIONS

Arrival will be between 8:50 am and 9 am. For arrival, please go to the middle parking lot between the buildings by entering on Athania Pkwy and exiting on Metairie Road. Our therapist and therapy techs will be outside ready to greet you and your child for the day! Please use our carpool for arrival so the carpool experience goes smoothly. Often when parents come into the building, some children can become upset, leading to a more challenging drop-off experience.

For pick-up, please arrive in the back parking lot and ring the doorbell. One of our staff members will buzz you into our waiting area and notify the lead therapists of your arrival. The therapists will bring your child to you and provide verbal feedback about their day.

FEEDBACK

Feedback will occur verbally at the end of each day and a printed go home note will be located in your child’s backpack every day. Pictures will be posted electronically on Brightwheel.

LATE ARRIVAL

We ask that your child arrives on time, no later than 9:10 am so they do not miss scheduled programming. If your child arrives later than 9:30 am on 3 occasions, your child’s attendance will be placed on hold. This is to ensure maximum benefit from our program and to avoid disruptions in your child's and the other participant’s routines.

LATE PICK UP FEE

Please note that you must pick up your child no later than 2:25 pm as we have afternoon outpatient clients beginning promptly after. If you arrive later than 2:30 pm to pick up your child, you will have a $25 late fee, and after 2:40 will be an additional $1 per minute the parent is late. If late pick up occurs more than 3 times, we reserve the right to dismiss your child from the program. Thank you so much for your cooperation in this matter!

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BEHAVIOR/SUPPORT POLICY

We understand that many children have behavioral challenges and benefit from a therapeutic environment; however, if we feel like the behaviors are outside of our scope of practice, we may recommend outside services or providers that can help those children with aggressive behaviors. We may ask you to pick up your child for an aggressive incident that is dangerous for the other children or staff. If your child has aggressive tendencies or demonstrates 3 or more aggressive behaviors toward other children or staff members while attending our program, we may recommend your child’s attendance to our program be placed on hold until other service providers are involved. Examples of these behaviors could include excessive biting, unprovoked aggression toward other children, or an excessive flight risk that would warrant one-on-one attention, etc. Refunds are not given in these instances.

We understand that some children benefit from having one-on-one support to succeed. Suppose it is discovered that your child needs more support than our program can provide. In that case, we will recommend your child be placed in an alternative TLC program that will better meet their needs, discontinue enrollment, and/or suggest other services with outside providers to ensure the child's success.

Divorced/Separated Parents and Custodial Arrangements

Therapeutic Learning Center, LLC does not get involved in disputes between divorced, separated, or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial, or other arrangement places that obligation on your former spouse or the child’s other parent. We will be happy to provide receipts for paid medical bills for you as requested. Feedback will be provided through the Brightwheel app and given to the caregiver who picks up the child. We are not able to provide feedback to multiple caregivers and ask that communication be shared among the caregivers.

ILLNESS

For the well-being of the children, please do not send your child when sick. NO CHILD WHO ARRIVES AT TLC, NOTICEABLY ILL, WITH A RASH, PINK EYE, EXCESSIVE COUGH, VOMITING, DIARRHEA, OR FEVER WILL BE ALLOWED TO ATTEND.

A child can return to the clinic once they are not experiencing any of the following symptoms for at least 24 hours.

Fever
Vomiting
Diarrhea
Contagious Rash

During the day, if your child experiences any of the following a parent or guardian will be notified immediately and asked to pick up your child.

Present with a 100.4 fever or more
Experiences vomiting
Experiences diarrhea
If your child becomes sick at home and cannot attend the program, please email programs@tlcnola.com, send a message via the Brightwheel app, or call our office at 504-565-7300 as soon as possible. Refunds are not provided for illnesses.

DRESS CODE (PLEASE LABEL ALL CLOTHES WITH FULL NAME)

Children are encouraged to wear comfortable play clothes and tennis shoes that can get stained. Daily activities include active and messy play, and the children should feel comfortable as they engage in a variety of play and projects. Clothing should allow for ease of potty training when managing their clothes.

TOILETING

If your child is not toilet trained, please provide necessary supplies for the daytime, including diapers, wipes, and a change of clothes. If you are using a reward system such as a snack, or toy, or reward chart, please send that as well so we can implement the program while they are at the center. Diapers and wipes should be replenished often.

SNACK/LUNCH & ALLERGIES

For the safety of all, we are a nut-free facility. Please do not send your child with any items containing nuts or nut-related ingredients of any kind. Thank you for your understanding and cooperation with this policy.

EMERGENCIES

In the event of a personal emergency, please call the office (504-565-7300) to notify us of alternate arrangements for the pick-up of your child.

If there is a weather event that requires your child to be picked up, we will contact you and request that you pick up your child immediately or make arrangements for a designated person to pick up your child. No refunds will be given for weather event-related closures.

Please notify TLC through email at programs@tlcnola.com or phone 504-565-7300 if:

Someone other than the usual person will be picking up your child. Your child will be released ONLY to persons you have designated on your information form under the pick-up list and will be asked to show an ID if we are not familiar with them.

TRIAL PERIOD:

While our number one goal is to create a fun and supportive environment to facilitate success for all of our children, there are times in which our staff ratio is not conducive to providing the level of support for those who require individual assistance to maintain safety and regulation throughout the day. Upon initial entry into the program, every participant will begin a trial duration of 30 days for our therapist to evaluate whether our program can provide the level of support needed to set your child up for success. After the trial period, the therapist will provide you with feedback regarding the suitability of this program to meet your child’s current needs and goals. If it is determined that the program is not designed to offer the level of support required for your child, we will provide recommendations for an alternate plan of action. This may include changing the length of time your child attends the program to half days until your child can tolerate a full day, temporarily discontinuing the program to seek out additional service providers, or requiring a shadow to provide individual support for your child throughout the day. Thank you for your understanding with this policy and please reach out with any questions or concerns.

TLC Day Programs TUITION:

You are not required to re-register every month. Once enrolled, your child’s admission is considered continuous until you, the parent, email TLC (programs@tlcnola.com), that your child will no longer be attending the program. If you do not have a set time frame for your child, the leading therapists will communicate with you regularly as to when your child is ready to graduate from the program.

Tuition is sent via invoicing to your email on file, from the “Brightwheel” app which houses our electronic invoicing system. Tuition is due in full on the last day of each month. Your payment will be based on the number of scheduled days that your child is to attend the program, and will vary depending on if you have chosen the 2-day, 3-day, or 4-day option. Tuition is to be paid electronically on the Brightwheel platform. Please note that your invoice may go to the spam folder; thus, you will need to ensure that

“support@mybrightwheel” is marked as a known contact email address in your email account to prevent this from occurring.

Invoices will be sent one week before the month your child will attend, unless there is availability to begin sooner. If your invoice is not paid by the last day of the month, your payment is considered late and you will be charged an additional fee of $25. If payment is not received by the 1st, a credit card will be REQUIRED to be maintained by TLC and your card will be charged with the late fee. If we do not receive a credit card from you, your child’s spot in the program will be placed on hold and he/she will be placed on our waitlist.

Please utilize our “autopay” feature offered through Brightwheel. This allows you to have a card on file and it will automatically charge you on the due date for the services. If you have any questions about this, please call our office or email programs@tlcnola.com.

REGISTRATION FEE/THERAPY SCREENING:

We require a completed intake form to register your child for the program. This form can be found at our website: www.tlcnola.com under the “Groups/Programs” tab. At the time of intake, we require a one-time nonrefundable registration fee of $75. This fee includes administrative costs, as well as screeners for Occupational Therapy and Speech Therapy Services. The screeners will allow the therapist to identify any delays and recommend individual therapy services if needed. Individual therapy services are not required for your child to attend our day program; however, our therapists will make recommendations accordingly. Ultimately, it is up to you to decide if you would like to add additional services for your child. If you are interested in pursuing individual services in addition to Building Blocks enrollment, please complete the intake form on our website under the “New Clients” tab for the discipline in which you are interested.

HOLIDAY CLOSURES:

We will be closed for observance of the following holidays: New Year's Day, Mardi Gras Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day.

ABSENCES/VACATION:

Refunds or prorating will not be issued for unexpected absences, expected absences, early pickup, or late arrival. This includes but is not limited to sick days, vacation days, or leaving early/arriving late due to personal commitments or prior appointments as we are continuing to hold the spot for your child.

WEATHER CLOSURES:

Refunds will not be issued in the event of unexpected TLC closure due to inclement weather.

DISCHARGE POLICY - GRADUATION/PROGRAM WITHDRAWAL:

TLC staff will schedule periodic parent conferences to discuss discharge and transition planning periodically to ensure the continued growth and development of your child.

Completion of our program will be discussed and determined during a parent meeting with the lead therapists in which all agree that your child has met the established goals and no longer requires the transitional program. We will not determine that a child is ready to graduate, unexpectedly, without alerting parents in advance to ensure that a transition plan is in place.

Refunds will not be issued for unexpected discharge or discontinuation of the program for any of the following reasons:

- Child behavior that is beyond our ability to control, that is harmful to others or themselves. No tuition or fees will be reimbursed.
-If your child shows aggressive behavior 3 or more times, we may recommend further evaluation by an outside provider. Following this evaluation, we will collaborate with the provider to discuss continued enrollment in the program and to ensure the safety and success of all of our children.
-Parental decision to pull from the program without warning (see below).
-Late pick-up on 3 or more occasions.
-Noncompliance with payment or other site policies and procedures.

Please note,that we require a one-week advance notice sent to programs@tlcnola.com if you plan to leave the program for any reason.

Written notice of program discontinuation is required to programs@tlcnola.com. No refunds will be provided within one week's notice.

If you have any questions or need us for any reason, please call the front office at 504-565-7300 or email programs@tlcnola.com.

We are looking forward to a fun adventure with your children!

Our best,

Your TLC Team

PLEASE READ AND ACKNOWLEDGE YOUR UNDERSTANDING OF OUR POLICIES AND EXPECTATIONS:

Parent/Guardian Signature*

Printed Name of Parent/Guardian*

Date*

Date