Camp Bloom Registration

Half-Day, 9am—12pm

Full-Day, 9am—2:30pm

Special requests

Child's name

First NameLast Name

Child's date of birth

Child's age

Child's school

Type N/A if not applicable.

Has your child attended Camp Bloom before?

Does your child have allergies?

If yes, list allergies below and let us know how we can accommodate. Please include special instructions and/or medical interventions which may be required.

Has your child been previously evaluated or received interventions?

If yes, please describe.

Do you have any concerns regarding your child's development or behavior? If so, please describe.

What would you like us to know about your child?

What do you hope your child will gain from this program?

Parent / Caregiver name

First NameLast Name

Parent / Caregiver email

Parent / Caregiver primary phone

Format: (000) 000-0000.

Parent / Caregiver other phone

Format: (000) 000-0000.

Home address (no PO boxes)

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Please list the best days, times, and method(s) to reach you.

Please let us know how you were referred.

Parent / Caregiver #2 name (optional)

First NameLast Name

Parent / Caregiver #2 email (optional)

Parent / Caregiver #2 primary phone (optional)

Format: (000) 000-0000.

Financial Responsibility and Attendance Policy

I understand that PAYMENT IN FULL IS DUE WHEN INVOICE IS RECEIVED to confirm my child’s registration and that Bloom Pediatrics, Inc. does not offer refunds, missed sessions cannot be rescheduled, and fees cannot prorated. I understand that I will NOT be charged if I am placed on a waiting list; if a space becomes available, Bloom will contact me I and I will have 24 hours to confirm registration.I understand that check or Zelle are the preferred forms of payment. I understand a 3% processing fee is added to all credit card payments. I understand that a $35.00 service fee will be charged for any checks or payments returned for insufficient funds. I understand that finance charges will accrue at 12% APR if payment is not received in our office within 25 days of the due date, and a minimum monthly finance charge of $15.00 will apply to all overdue payments.I understand that in order to provide security of payment to Bloom, I must provide credit card information. I understand that if my account is 30 days past due, Bloom will automatically charge the credit card on file to cover my outstanding balance, including finance charges or a minimum fee of $15.00, whichever is greater. I understand that past due balances exceeding $1000.00 will result in services being placed on hold until a payment plan has been established.I understand that Bloom reserves the right to terminate treatment if payment for services is not received. I understand that Invoices more than 90 days past due are considered to be in default and that I will be charged cost recovery fees if Bloom must take collection action to resolve payment delinquencies. Cost recovery fees may include small claims fees, attorney fees, enforcement fees, collections fees and lien fees. I acknowledge and accept the financial responsibilities and security of payment policies above.

Cancellation and/or Closure Policy

Consent for Use of Equipment and Emergency Treatment

In case of an emergency and I am not present, I give permission to the personnel of Bloom Pediatrics, Inc., into whose care my child has been given, the authority to consent to an x-ray examination, anesthetic, medical or surgical treatment and hospital care to be rendered under the supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical or Dental Practice Act.In the event of a medical emergency and I am not present, I understand that the staff of Bloom will contact 911 or other appropriate medical personnel. If ambulance service must transport my child, I understand that it will be to the closest medical facility able to handle the situation. I understand that my child’s records are protected under state and federal confidentiality regulations and cannot be disclosed without prior written consent. I give my consent to allow the release of information and/or records/reports regarding my child for purposes of emergency medical treatment. I understand the staff of Bloom Pediatrics, Inc. will not be liable for any first aid treatment, medical or hospital care rendered, or drugs, medicine or surgical procedures performed pursuant to this consent.

Sick Policy, Soiled Clothing, and Head Lice Policy

In consideration for the health of our clients, therapists, and staff, Bloom requires that parents or caregivers do not send their children if they exhibit any of the following: • illness symptoms within the last 24 hours • fever: temperature of 100°F or greater within the last 24 hours • vomiting within the last 24 hours • sore throat or difficulty swallowing • mouth sores, eye discharge, unusual nasal discharge, uncontrolled coughing, difficulty breathing or wheezing, and/or wounds that are not properly covered. I understand that if my child exhibits or develops any of these symptoms during their time at Bloom their activity will be ended and the parent, caregiver, or emergency contact will be immediately contacted to pick them up.

Communication and Correspondence Policy

Bloom staff may share progress and discuss other information after sessions. To ensure privacy and in consideration of any confidential information that may be part of this discussion, please indicate below which methods of communication are acceptable for conversation. If ONLY the text message, phone and/or email options are selected below, Bloom staff may need to schedule additional time to allow for adequate communication, which will be billed at the hourly session rate.

Video and Picture Consent

Social Media and Web Consent

I GIVE CONSENT to have my child’s photographs to be displayed on Bloom's website and social media in order to share my child’s accomplishments and demonstrate their work done at Bloom. I release Bloom, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. I hereby agree to hold Bloom, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor’s behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor’s likeness and photograph. If I wish to revoke my permission in the future, I will submit my request in writing to Bloom.

We may share weekly Camp Bloom activities in a newsletter format. The newsletter is only shared with parents / caregivers of children who are enrolled in camp during that week. It is not used for any other purpose. If you choose to decline consent now, or if you choose to revoke consent at any time in the future, you may do so without any impact on your child's care with Bloom.

Camp Newsletter Photo Consent

HIPAA Notice of Privacy Policies

I attest that I understand and agree to the following: HIPAA NOTICE OF PRIVACY PRACTICES In compliance with the Health Insurance Portability and Accountability Act’s Privacy Rule (HIPAA), your child’s private health information (PHI) will be protected in his/her medical records, in consultation with other professionals involved in your child’s care and with payers, HIPAA requires that your child’s PHI be kept private and that you are notified of the privacy practices with respect to your child’s PHI. A summary of the policies follows. MEDICAL INFORMATION Your child’s PHI may consist of evaluations, diagnosis, daily notes, progress notes, Individual Family Service Plan (IFSP) Individualized Educational Plan (IEP), insurance information, physician prescriptions, and correspondences to your other medical and educational providers (e.g., physician, therapists, service coordinators, psychologists, social worker, school personnel, etc.) COLLECTION, STORAGE, DISCLOSURE AND DISPOSAL OF MEDICAL INFORMATION • Your child’s records will be kept in a file with his/her name on it. These files are stored in a locked container in your therapist’s home office or in a central file at our office. Your child’s records may also be stored in a computer only accessible to your child’s therapist(s). • Correspondence with others regarding your child’s PHI will only include other members or your current child’s healthcare provider team to discuss your child’s course of treatment. • At your request, correspondence with outside consultants or educational personnel will be made. Your written consent is required for this communication to take place. • All phone correspondence with other members of your child’s healthcare team or payer will be conducted on a private phone line in a confidential manner, so others cannot hear the conversation. • All faxed information about your child will include a fax coversheet with a confidentiality statement. No confidential information about your child will be included on the fax cover sheet. • Correspondence by mail will be addressed to specific individuals for the purpose outlined above. • A written record of all disclosures of your child’s PHI will be kept. • Only the Minimum Necessary Requirements will be disclosed to the entity requesting information. This means that only the minimum amount of information necessary to complete the task for which the entity is requesting the information will be provided, rather than sending the entire le. • Your child’s therapist is your child’s Privacy Officer. Each therapist is responsible for protecting your child’s PHI and following these guidelines. • Your child’s records will be kept and stored for a minimum of 6 years. After this time, the records will be shredded to protect privacy. YOUR RIGHTS UNDER HIPAA • You have the right to inspect and copy your child’s personal health information. The request must be made in writing. • Your child’s PHI will be used strictly for evaluation and treatment planning. • You have the right to request information about who PHI has been released to. • You have the right to take away permission to disclose information to any party at any time. This request must be made in writing. • You have the right to complain if you believe your privacy rights have been violated. if you feel your rights have been violated, please contact us. You may also file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights at hhs.gov/ocr/privacy/hipaa/complaints/, 877.696.6775, or U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, SW; Washington, D.C., 20201. We will not retaliate against you for filing. SUMMARY OF RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will give you a hard copy of this notice and follow the duties and privacy practices described in this notice. We will not use or share your information other than as described here unless you tell us in writing that we can. You may also change your mind at any time and let us know in writing if you do. Additional information is available at hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html TERMS OF CHANGE We can change the terms of this notice. Any changes to this notice will be available to you upon request, on our website, or office. These changes will apply to your information we have on file.

Emergency Contact (must be someone other than primary parent/caregiver)

First NameLast Name

Emergency Contact primary phone

Format: (000) 000-0000.

Emergency Contact relationship to child

Please select your preferred method of payment below. You will receive an invoice by email. Zelle or check is the preferred form of payment. A 3% convenience is added to all credit card payments made online. Payment in full is due when invoice is received. Credit card information must be provided for security of payment after registration submission.

By signing below, I attest that I understand and agree to the terms and conditions outlined above.

Print name

First NameLast Name

Today's Date

Date

Camp Bloom Registration

Camp Schedule

Child Information

Parent / Caregiver Information

Required Forms

Payment Information

Parent / Caregiver Signature and Date