2023-24 MLC Registration

If your child is new to Miriam, you will be contacted by the Miriam Learning Center staff to determine if your child would benefit from the services you select below. For returning children, you will receive an email confirmation of your chosen programs/services. If you have any questions, please call 314-961-1500.

How did you hear about our programs?*

Child's Name*

First NameLast Name

Child's Birth Date*

MonthDayYear

Child's Gender*

Child's Race*

Child's Diagnosis*

Other diagnosis description

Annual Household Income - This is compiled for grants and other funding sources*

School for 2023-24 school year*

Grade for 2023-24 school year*

Is your child new to Miriam? *

NoYes

Copies of my child's educational records can be obtained from

If the participant is 18 years or older, is he/she their own guardian?*

YesNoNot applicable (under 18 years old)

GUARDIANSHIP & EMERGENCY CONTACT INFORMATION

With whom is child living?*

Legal Guardian 1 Name*

First NameLast Name

Legal Guardian 1 Relationship to Child*

ParentOther family memberCourt appointed guardianOther

Legal Guardian 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Legal Guardian 1 E-mail*

example@example.com

Legal Guardian 1 Primary Phone*

Area CodePhone Number

Legal Guardian 1 Secondary Phone

Area CodePhone Number

Legal Guardian 1 Place of Employment

Legal Guardian 1 Work Phone

Area CodePhone Number

Parent/Guardian 2 Name

First NameLast Name

Are you the child's legal guardian?

YesNo

Parent/Guardian 2 Relationship to Child

ParentOther family memberCourt appointed guardianOther

Parent/Guardian 2 Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian 2 E-mail

example@example.com

Parent/Guardian 2 Primary Phone

Area CodePhone Number

Parent/Guardian 2 Secondary Phone

Area CodePhone Number

Parent/Guardian 2 Place of Employment

Parent/Guardian 2 Work Phone

Area CodePhone Number

Emergency contact name*

First NameLast Name

Emergency contact address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency contact e-mail*

example@example.com

Emergency contact phone*

Area CodePhone Number

I am interested in Educational Services for my child. Please contact me regarding the following

Specialized tutoring at Miriam School & Learning CenterVirtual teaching and/or tutoringIn-School SupportsStudy Skills TrainingExecutive Function TrainingOther TutoringEducational Consultation/Help with IEP or 504 Plans

I am interested in Behavioral Health Treatment for my child. Please contact me regarding the following

Counseling/Cognitive Behavior TherapyIn-School Behavior AidFunctional Behavior Assessment (FBA)Applied Behavior Analysis (ABA)Board Certified Behavior Analyst Consult (BCBA)

I am interested in Therapy for my child. Please contact me regarding the following

Music TherapySpeech/Language TherapyOccupational TherapyPhysical Therapy

I am interested in Diagnostics for my child. Please contact me regarding the following

CONSENT AND RELEASE FOR PARTICIPATION

I consent for my child to participate in the Miriam Learning Center's Programs. I agree by this consent to hereby release and discharge the said Miriam Learning Center, its agents, employees, and officers from all actions, causes of action, damages, claims or demands which I, my heirs, personal representatives or administrators or assigns may have against said organization and other above mentioned parties from all injuries known and unknown which such person may incur by participating in the above described activity and program(s).

I have read the above Consent and Release and understand its terms. I execute it voluntarily and with full knowledge of its significance.*

I agreeI disagree

PARENTAL AUTHORITY

Miriam does not withhold testing and other treatment information from parents/guardians who have the legal right to make decisions about a child. If family disputes arise, Miriam will request legal custody documents to ensure a parent/guardian has decision-making authority. I certify that all parents/guardians with legal custody and/or decision-making authority are aware the student is participating in services at Miriam and that these individuals approve of the services Miriam is providing.

I agree to the above described Parental Authority.*

Yes

MULTIPLE DISCIPLINES TEAM APPROACH

If your child receives more than one service through Miriam Learning Center, staff involved may have access to the other disciplines' notes including mental health information. This is to best serve your child from a team approach. Please agree or disagree with the statement below.

I agree to allow Miriam staff involved in my child's treatment access to all treatment information on a need-to-know basis.*

I agreeI disagree

FINANCIAL AGREEMENT FOR SERVICES

Miriam Learning Center does not accept medical insurance. A coded superbill may be provided upon request for you to submit to your insurance company. Payment is due at the time of service. Services may be discontinued when accounts are 30+ days in arrears and 15% interest will be charged on the balance. A $25 fee is assessed on returned checks. I was provided the rate for requested services.

I have read the above Financial Agreement for Services and agree to pay for services at the agreed upon rate*

YesNoPayment by third party

PICTURE/VIDEO TAPING/AUDIO RECORDING RELEASE

Children in Miriam's programs can be photographed and video/audio recorded for public relations/fund raising purposes. They also may be photographed and/or audio/video recorded for program purposes, such as projects. Please indicate your permissions below for both public relations and program purposes. This authorization is valid until the parent/guardian rescinds his/her permission.

Public Relations Photo/Audio/Video Permission Preference*

I agreeI disagree

Program Photo/Audio/Video Permission Preference*

I agreeI disagree

TeleHealth VIDEO/AUDIO THERAPY & TUTORING RELEASE

Children enrolled in Tutoring, OT, S/L Therapy, and Counseling may opt to receive treatment at their home via secure video/audio conferencing using Zoom, Skype, Apple FaceTime,Theranest, and many other applications. We will not use public facing applications such as Facebook Live, Twitch, Tik Tok, etc. Third-party applications potentially introduce you to privacy risks. Please indicate your permission below regarding computer, tablet, or phone-based video/audio conferencing services. An adult 18 years or older must be present in the home for the TeleHealth services. It may also be used in conjunction with in-person services.

TeleHealth Permission*

I agreeI disagree

MEDICAL RELEASE TO TREAT

In the event of an injury to my child, or an existing condition indicating the need for minor first aid (e.g., bandage, cold pack, splinter removal, etc.), I hereby give my permission to administer these types of procedures. If time is critical, Miriam has permission to take my child to the nearest hospital for emergency care. I agree to pay all expenses incurred by this care.

I agree to the above described medical care and expenses*

Yes

ALLERGY/MEDICAL INFORMATION

Food Allergies*

NoYes (describe below)

Food Allergy Description

Medication Allergies*

NoYes (describe below)

Medication Allergy Description

Other Allergies*

NoYes (describe below)

Other Allergy Description

Primary Care Physician Name*

First NameLast Name

Primary Care Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Care Physician Phone*

Area CodePhone Number

ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES AND PARTICIPANT HANDBOOK

Click here to view Miriam Learning Center Notice of Privacy Practices

Click here to view Miriam Learning Center Participant Handbook

I hereby acknowledge that I have received/read the above copies of the Miriam Learning Center Notice of Privacy Practices and the Miriam Learning Center Participant Handbook. I also understand the Learning Center's cancellation policy requiring a minimum 4 hours notice of cancellation. The cancellation policy applies to both in-person and remote services.*

YesNo

AUTHORIZATION TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION

I understand that by completing the information below and submitting this form, I am giving permission to release/receive the designated confidential information for one year from the date of my electronic signature. I understand that I may withdraw this permission at any time during the period by stating my request in writing.

ALL INFORMATION WILL BE KEPT CONFIDENTIAL

I hereby authorize Miriam and my school to obtain/release information regarding my child including personal, educational, social, psychological, psychiatric, medical records, and opinions with the below listed school.*

YesNo

Electronic Signature of Parent/Guardian*

Child's Name

First NameLast Name

Child's Birth Date

Date

Name of School Contact

Position

Name of School

Email

example@example.com

Phone Number

Area CodePhone Number

Enter the message as it's shown*

Date Submitted*

MonthDayYear

Learning Center 2023-24 Registration