Fit Kids Registration and Release 12/5-2/20

Fit Kids Registration and Release 12/5-2/20
Child's name*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Parent/Caregiver's Name*

First NameLast Name
Is the participant a current BAC patient?

YesNo
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Allergies (please include type of reaction)
Medical Precautions and/or Adaptive Equipment Needs
I have spoken to a BAC clinician to confirm that this group is an appropriate fit for my child. (Required prior to registration)*

YesNo
I understand that I am responsible for payment, there are NO makeup’s for missed sessions due to my child’s sickness, vacation, or general absence.*

Yes
I understand that all payments for groups are out of pocket and NOT billed to my insurance company.*

Yes

In Case of Emergency...
Primary contact in case of emergency*

First NameLast Name
Primary emergency contact phone number*

Area CodePhone Number
Primary contact email address*
example@example.com
Secondary contact in case of emergency*

First NameLast Name
Secondary emergency contact phone number*

Area CodePhone Number
Our policy is to call 911 in the case of any medical emergency. Please indicate if you would like us to do otherwise, and what action you would like taken:
In the case of an emergency, it is likely that your child will be transported to Newton-Wellesley Hospital. If you prefer that your child be taken to a different hospital or facility, please indicate below.
I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, if any, while attending or participating in any facility exercise program, sport or physical activity at the Boston Ability Center. I hereby waive all claims against, its instructors, or partners of the program, individually or otherwise, for any and all claims for injuries or damages that I might sustain.

I understand that there is risk of injury associated with participating in any facility exercise, program, or sports activity. I certify that I am in good physical condition and have no known disabilities that might otherwise be detrimental to my health or well-being. I certify that all of the information provided on this application is correct and true to the best of my knowledge.

All applicants must sign. Parents or guardians must sign if applicant is UNDER 18.
Signature of Parent/Legal Guardian:*

Clear
Name of Parent/Legal Guardian:*

First NameLast Name
Date:*

MonthDayYear

Photo and Video Consent Form

(optional)
I hereby grant The Boston Ability Center permission to use my child’s likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of The Boston Ability Center and will not be returned. I hereby irrevocably authorize The Boston Ability Center to edit, alter, copy, exhibit, publish or distribute photos or videos for purposes of publicizing The Boston Ability Center’s programs or for any other lawful purposes. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein the likeness of my child appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of photographs or videos. I hereby hold harmless and release and forever discharge The Boston Ability Center from all claims, demands, and causes of action which I, my heirs, representatives, administrators, or any other persons acting on my child’s behalf may take.
Parent/Guardian Signature

Clear
Parent/Guardian Printed Name
Date

MonthDayYear
Date

Consent Form for Assisting with Toileting Needs

Version: 2023
BAC staff are committed to meeting the needs of all children and working collaboratively with families to help children achieve their toileting goals. As such, BAC staff are happy to assist children with toileting as needed and will take all reasonable precautions to ensure the safety, privacy, and dignity of each child when providing toileting assistance. Depending on your child's needs, this may include tasks such as diaper changing, helping a child access the toilet, assisting a child with wiping or managing clothing, assisting a child with hand washing, and/or changing a child following an accident.
Please indicate your preference by checking the appropriate box below:*

I give consent for BAC staff to assist my child with toileting as needed. If my child is not yet potty trained or is prone to accidents, I will send them to their appointment with extra briefs/diapers and clothes.I do NOT give consent for BAC staff to assist my child with toileting. If my child is not yet potty trained or is prone to accidents, I understand that a caregiver will be asked to remain in the waiting room for the duration of my child's appointment(s) to assist with toileting/diaper changes as needed.
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Print Name of Legal Guardian*
Child's Name*

First NameLast Name

Fit Kids Registration and Release 12/5-2/20

In Case of Emergency...

Photo and Video Consent Form

Consent Form for Assisting with Toileting Needs

Payment