Indie Developmental Program Registration
Please fill out all relevant sections to the best of your ability. Questions can be directed to info@indielearningco.com.
Child's Information
Name
*
First Name
Last Name
Does your child have any nicknames?
Birth Date
*
-
Month
-
Day
Year
Date
Anticipated Enrollment Date
*
Session
*
Please Select
AM Session
PM Session
Schedule
*
Please Select
5 Day (M-F) HALF DAY
3 Day (M,W,F) HALF DAY
2 Day (T, Th) HALF DAY
5 Day (M-F) FULL DAY
3 Day (M,W,F) FULL DAY
2 Day (T, Th) FULL DAY
Billing Preference
*
Private Pay (Billed monthly)
ESA Reimbursement (Billed monthly)
ESA Classwallet submission (Billed quarterly)
Recommended by a friend? Enter your referral code!
Parent/Caregiver Information
Parent/Caregiver #1
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver #2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contacts
Please provide a minimum of 3 people who we can contact in case of emergency. Include their full name and phone number.
*
Are the above listed emergency contacts allowed to pick up your child from our program?
*
Yes, all the emergency contacts are allowed to pick up my child.
No, my emergency contacts are not allowed to pick up my child.
If there is an exception to the above question, please list emergency contacts who are NOT permitted to pick up your child from our program.
I understand that Indie WILL NOT release my child to individuals NOT listed on the emergency contact list.
*
Yes, I understand.
I understand that ALL emergency contacts may be asked to produce a photo ID upon pick up of my child from the Indie program.
*
Yes, I understand.
Academic
Has your child ever been enrolled in a traditional academic program?
*
Yes, PreK-Kindergarten
Yes, Elementary
No
Which grade, if any, was your child last placed?
If applicable, please upload your child's most recent IEP.
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Therapy
Which therapies, if any, has your child participated in? (Past or Present)
*
ABA therapy
Occupational Therapy
Speech Therapy
Physical Therapy
Music Therapy
Other
None
If other, which?
What has been your child's experience with traditional educational/therapeutic environments? What barriers, if any, have you identified within these environments that impacted your decision to consider other options?
In other words, what misses the mark within these environments that prompted you to explore other options.
Food & Allergens
Does you child have any food allergies?
*
Yes
No
Does your child have any safe or preferred foods?
*
Please list and describe how they prefer to eat their safe food (i.e. likes mac & cheese cold or likes veggie sticks broken up into smaller pieces)
If yes, are they anaphylactic to any of the following allergens?
Dairy
Eggs
Soy
Gluten
Peanuts
Tree Nuts
Shellfish
Fish
Sesame
Other
Please describe your child's food allergens/reactions
If applicable
If applicable, please upload your child's allergy plan
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Medical
Does your child have any diagnoses?
*
Yes
No
Awaiting evaluation
If yes, select any of the following that apply
ADHD
Autism
Apraxia of Speech
Asthma
Cerebral Palsy
Cystic Fibrosis
Diabetes
Down Syndrome
Epilepsy
Sickle Cell Disease
Spinal Muscular Atrophy
Williams Syndrome
Other
Tell us anything you'd like us to know about your child's diagnoses.
Any relevant information to help us best support them while attending our program!
If applicable, please upload any emergency/medical plans
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i.e. seizure plan, asthma plan...etc
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If your child will be receiving medication during their session, please upload a summary of all medications including dosages, times administered and methods that work best for your child (i.e. likes apple juice after taking medication).
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Does your child have an aide, attendant or nurse that will be accompanying them to their session? (Aides are not required for your child to attend, but if they have existing support staff that you'd like to send with them, this is perfectly fine!).
Yes
No
Aide/Nurse's Full Name
First Name
Last Name
Company
If your aide/nurse is contracted through a company
Phone Number
Please upload your child's aide/nurse's fingerprint clearance card
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This is required prior to your child's aide accompanying them to their session
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Independent Living Skills
How does your child currently utilize the bathroom?
*
Independent toileting
Supported toileting
Diaper/pull-up
Other
If other, please give us any relevant details that would help us best support your child's toileting/bathroom needs.
If your child is currently supported toileting or using diapers/pull-ups, please give us any relevant details that would help us best support your child's toileting/bathroom routine.
i.e. how is your child currently changed (standing or on a changing table), which steps does your child benefit from support within their toileting routine?
What is your child's current stage of feeding?
*
Independent feeding by mouth
Supported feeding by mouth
Via G-tube
Other
Does your child have a diagnosis of PICA or benefit from support in differentiating edible/non-edible items?
*
Yes
No
Please give us any relevant details that would help us best support your child's feeding needs.
Accommodations
Does your child benefit from accommodations for any of the following?
Communication Accommodations (communication boards, low-tech AAC, visuals)
Hearing/Auditory Accommodations
Physical Accommodations (mobility aids, adaptive seating)
Sensory Accommodations
Visual Accommodations
My child has a light sensitivity/sensitivity to flashing lights
If your child utilizes adaptive equipment (toys, utensils, mobility devices, AAC devices), could you tell us a bit about each? Which of these would they benefit from in a group setting?
i.e. my child would benefit from adaptive seating options within their classroom
Which sensory items are most important to your child? (i.e. headphones, fidgets, weighted blankets, swings, light toys). If your child has comfort items, let us know!
Is there anything else that we should know about your child, necessary accommodations or comfort items in order to best ensure their safety and comfortability as they attend our program?
Disclosures
Each child receives a comprehensive assessment from their multidisciplinary team as they enter the program. This assessment is used to compile your child's "learner plan" and inform provider recommendations for academic/pre-academic goals, therapy hours, small group sessions and individualized support. All assessments are as informal and naturalistic as possible, using play-based strategies. All learner plans are written from a strength-based lens and shared with the parents/caregivers upon the completion of each assessment. This assessment and any relevant parent/caregiver meetings are at no additional cost to the family.
*
I consent to my child's assessment by their multidisciplinary team (teacher, speech therapist, BCBA, OT)
During our program, providers may take photo/video of learners, artwork, creations and activities to be used on Indie Learning Co's website/social media platforms. This media is purposed to inform the public about the work that we do at Indie, and teach about play-based, naturalistic strategies within educational and therapeutic settings. All posted media is free from identifying information, including learner name, age, diagnosis and specific areas of support.
*
I consent to photos/videos being taken of my child
I consent to photos/videos being taken of my child, with the omission or blurring of their face on Indie Learning Co's website/social media platforms
I do not consent to photos/videos being taken of my child
I acknowledge that Indie is a full-year program, and tuition is billed each month according to learner's enrollment schedule. Monthly tuition is not discounted or pro-rated for instances such as vacation, illness, federal holidays or other temporary absence. If my learner is going to be unenrolled from Indie, 30 days written notice is required.
*
I acknowledge and accept Indie's tuition policy
I acknowledge that my tuition invoice must be paid within 7 days of receipt.
*
I acknowledge and accept Indie's tuition policy
I acknowledge that snacks will be provided for my child by Indie and that any snacks from home must be cleared with my child's teacher in order to avoid introducing allergens into the space.
*
I acknowledge and accept Indie's snack policy
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