Small Groups Application 2025

Starting the week of Sept. 22nd

Early Bird Discount 20% off

In effect through September 30th, 2025

$100 deposit: Balance $395

Standard pricing

Resumes October 1st:

$100 deposit: Balance $515

*INCLUDES a free T-shirt

Child's Name*

First NameLast Name

Allergies list allergies* . Allergies to farm animals ? *

Likes and dis-likes ? . Favorite snacks / food?

DOB . My child prefers to be called .

Does your child have any allergies ?

T-Shirt size*

If there are challenges in the areas of emotional awareness, self regulation, social skills, health and wellness, or others challenges that may effect groups participation please let us know in the space provided.?allergies

Are you registering for the 4 -5 yr old "Academic Readiness Group? age . If yes, what is your child's current age? .

Responsible Party*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Which Exceptional Me OPEN small group time / age would you like to attend ? Child must be potty trained*

Payment Agreement

-The Exceptional Me Program runs in 8-week increments throughout the academic school year. Groups meet 1 time a week for 2 hours per meeting fro . The cost listed above is per eight week session (exception: a seasonal or event discount is in effect and has been applied). Price is adjusted accordingly in the check out options.

-If joining after an eight week session has begun, a prorate will be calculated for the reminder of the session resuming the stated 8 week price for the following session.

-Each child:One free T-shirt is provided and should be worn each week while attenting groups.

-Payment is due the week before each session begins. No later than the Friday before each session begins.

-Unless prior arrangements have been made with our coordinator, if payment in full is not received the week before each session (no later than the Friday before), we will recognize that confirmation of your child's intention to attend has not been confirmed. Because space is limited and demand is high, we may need to offer the opportunity to join another child who is on our waiting list. This may cause the loss of the $100 deposit.

-Even if there is an increase in cost posted on our web-site, the rate you received at the time of your sign up will renew and remain in effect as long as your child consistently remains in the Exceptional Me Program for the remainder of the academic school year in which they joined.

-$100 non-refundable deposit is due with application. Payment link is provided below. This deposit holds your child's place and will be applied to the remaining balance for the first session attended. A deposit is only required when first entering the program.

-Due to the importance of attendence when enaged in small groups and discounts offered, once a group session is paid for in full and has begun, any missed meetings by the child are forfited and weekly attnedance is encouraged.

-If the Instructor must cancel a class due to unforeseen circumstances or illness, the class will be made up by extending the session 1 week.

Responsible Partyname . Date date signed

Signature of responsible party*

Personal Injury Waiver Form

This Personal Injury Waiver (the "Waiver") is made by the undersigned for the purpose of utilizing the facilities and premises managed by OT4KidsInc., (the "Company"), with the location at 440 Central Ave, NC 27292. and in the acknowledgment that in the utilization of the premises and facilities of the Company, occupies risk of personal injury that may arise or happen at any time.

In consideration of the Company allowing the undersigned to make use of the venue and its facilities and equipment for the relevant purpose by which the Company allows, the undersigned agrees to assume the foreseeable and unforeseeable risk of personal injuries related to the activity, and agrees to release, discharge, and hold harmless the Company, its owner(s) and employees free from any and all liabilities, claims, cause of action, damages, or losses, which may be incurred by the undersigned in using said premises and its equipment and/or facilities, and which may arise from any reason whatsoever, specifically including, but not limited to, any negligence on the part of the owners, its employees, or losses arising from theft or for any other reason whatsoever.

This Waiver shall be binding upon the parties, their respective heirs, representatives, successors, and assigns.

In case any part of this Waiver be construed as improper or invalid, such invalidity will affect only that part of this Waiver and the rest shall remain valid and enforceable.

Any alteration, modification, or amendment to this Waiver shall not be considered as valid unless otherwise written and signed by the undersigned herein.

Name of responsible party parent or legal guardian . Date date signed .

Signature*

I hereby grant The Exceptional Me and OT4 Kids inc. staff the irrevocable right and permission to use photographs and/or video recordings of me and/ or my child on OT4 Kids and other websites, publications, social media platforms, in promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me. This request is in efforts to offer this small groups opportunity to others who can benefit from the unique setting the Exceptional Me Program offers.

to the above statement*

Signature*

My Products : Following completion of this form, please move forward to complete the final payment form before the deadline *

Deposit: Hold My child's place Product Image

Deposit: Hold My child's placeDeposit is required to register, applied to the balance, and is non refundable. A payment link will be send to you for the remaining balance which is due 1 week before the group starts.

$100.00 Quantity

T-Shirt free

$ Free Quantity

For Administration

$ Free Quantity

Total

$0.00

SIGN up EXTENDED Exceptional Me