Peer Group Registrations

Peer Group Registration Form

Fill out the form carefully for registration. Please note that this form is not HIPAA compliant. If you have any protected health information to share, please schedule a phone call at 440-972-3670 Ext. 503. Thank you.
Student Name*

First NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Name*
Parent's E-mail*
example@example.com
Mobile Number*
Phone Number
Check

Peer Group Ages 8-11, 6 Fridays, September 19, 2025-October 24, 2025, 4:45-6:15 pm)
Please indicate if you would like to share your contact information with other families for arranging meet-ups outside of the group.

YesNo
Additional Comments

Signature*

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Consent for Peer Groups (Medical Treatment and Pictures)

* indicates a required field
* I hereby give consent for the following medical care providers and local hospital to be called:

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Doctor's name and phone #:
Dentist's name and phone #:
Name of Hospital and phone #:
* In the event reasonable attempts to contact me or the other contacts listed have been unsuccessful, I hereby give my consent for the admission of any treatment deemed necessary by the above name doctors, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and the transfer of the child to the above referenced hospital or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Please list any information concerning the participants medical history including ALLERGIES and any PHYSICAL IMPAIRMENTS to which a physician should be alerted:
Uses an Inhaler?

YesNo
Wears Contact lenses?

YesNo
Does this participant have an Epipen or similar device? If so, please make sure that Bright Futures staff are aware of where it is kept and have proper training on when and how to administer if needed.

YesNo
REFUSAL For CONSENT: I DO NOT GIVE MY CONSENT for emergency medical treatment of my child. in the event of illness of injury requiring emergency medical treatment, I wish Bright Futures staff to take no action:

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Refusal: Please type your response of what you would like the staff to do in the event of emergency.

Intake Questions for Peer Groups

* indicates a required field
* Please List the Primary Contact's Name and Phone Numbers: (Home and Cell Phone)*
* Please List a Secondary Contact's Name and Phone Numbers: (Home and Cell Phone)*
* Please list any allergies or medical needs your child may have:
Describe your child's communication skills. Are they able to hold conversations with others?
Please list your child's special interests:
Please list your child's favorite hobbies or activities here:
Does your child need help using the restroom? Please list what kind of help is needed:
If my child needs help using the restroom, I give permission for a Bright Futures staff member to help my child.

YesNo
Please let us know any other information about your child that may be helpful. Include anything that would be helpful for staff to ensure a positive experience for your child, such as sensory interests or aversions, potential for anxiety (and what may help), etc.
Permission for sharing your child's photo

Sharing with other Peer Group parents onlySharing on the Bright Futures website and advertising onlySharing with other parents in the group and on the website/advertisingI do not give permission for my child to be photographed

My Products

Peer Group: 6 sessionsPay by debit/credit

$300.00 Quantity

Pay by checkPlease mail a 300.00 check for 6 sessions endorsed to Bright Futures Therapeutic Services, LLC. Mail to Bright Futures Therapeutic Services, LLC, 8972 Darrow Rd. Suite A-204, Twinsburg, OH 44087. Please note Peer Group ages 8-11 in the notes section. Admission into the group is dependent on receipt of the check before the first day of group. Thank you.

$ Free Quantity

Total

$0.00

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

Should be Empty:

Peer Group Registration Form

Consent for Peer Groups (Medical Treatment and Pictures)

Intake Questions for Peer Groups