Connection Crew Registration Form

Registration Form

Calling all crew members!

Welcome to The Connection Crew, where friendships are built and fun is always in the mix! This exciting group is all about exploring social skills through hands-on activities and creative teamwork.

WHAT IS CONNECTION CREW: A four-week social skills group led by Licensed Speech Therapists and Occupational Therapists that provides a structured, safe and supportive environment for children to practice social interactions with peers through play with Legos.

WHEN:  Tuesdays – October 22nd and 29th and November 5th and 12th from 5pm – 6pm

WHERE:  Premier Pediatric Therapy Source’s clinic location
6715 Little River Turnpike, Annandale, VA 22003

COST: $440.00 for 4 sessions (40% off until 10/16/24)

PURPOSE:  To foster opportunities for both verbal and non-verbal interactions with peers in a fun group atmosphere with skilled support and attention to facilitate improved social skills.

Our spirited and playful Speech and Occupational Therapists will provide individualized support based on your child’s needs to facilitate social interactions with peers.

WHO is best suited for this group: This class is geared towards children 5-10 years
- Children who are able to follow simple directions for game play, can sustain joint attention and attend to activities for up to10 minutes
- Children who can engage in safe behaviors
- Children who have difficulty participating in group activities at school, initiating peer interactions and making friends
- Children who are independently mobile
- Interest in building with Legos is a plus!
What will participants get out of Connection Crew: Opportunities to…
- Engage in fun, social activities in small, structured groups with similar aged peers
- Bolster and enrich basic concepts necessary for age-appropriate social play including joint attention, perspective-taking, turn-taking, problem-solving, instruction sequencing, and emotional regulation
- Increase comfort level with initiating and navigating social interactions with peers
- Collaborate with peers while boosting creativity and imagination
What to bring:
- A positive attitude and readiness for fun!
- Comfortable clothes and shoes for moving around
What to expect:
- Parking: You may park on side or back parking lot of the building at Premier Pediatric Therapy Source
- Bathrooms will be available on site however parents should have their child(ren) use the restroom before each class
- Connection Crew registration, waiver form, and payment must be completed prior to participation
The following forms are included within this registration packet and must be completed prior to participation:
1. Registration and emergency contact form
2. Participant Waiver
3. Photo Release Opt in/out Consent
4. Payment

Connection Crew Social Skills Group Participant Waiver
Waiver & Release of Liability: PLEASE READ CAREFULLY BEFORE ACCEPTING PARTICIPATION. THIS IS A RELEASE OF LIABILITY & WAIVER OF CERTAIN LEGAL RIGHTS.
I blanks the parent/legal guardian of blank, voluntarily release and hold harmless PREMIER PEDIATRIC THERAPY SOURCE, INC.“PPTS” and it's volunteers from any and all claims, demands and causes of action whatsoever, arising out of or related to any and all claims of loss, damage, or injury, that may be sustained by the participants and/or the undersigned, while engaging in the SOCIAL SKILLS GROUP (“CONNECTION CREW").
I agree to abide by and follow all safety rules presented during the CONNECTION CREW social skills group and willingly and knowingly assume for myself and the minor participant, all risk of physical injury or emotional distress which may occur during any class, and I agree to hold PPTS employees and it's volunteers harmless from any and all liability arising from participation. I understand, agree, and acknowledge that there are risks inherent to bike riding activities and that these activities may be of a hazardous nature.

With full understanding of the facts, I state that to the best of my knowledge I, or my child listed above, has no medical, physical, or emotional health conditions, which would hinder or prevent participation in the CONNECTION CREW group. I also understand that this form must be signed by the adult participant and/or parent/legal guardian of a participant under 18 years of age prior to participating in the CONNECTION CREW social skills group.

I HAVE CAREFULLY READ ALL OF THE ABOVE INFORMATION. I ACCEPT AND ACKNOWLEDGE IT WITH FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE. I UNDERSTAND THAT THE INFORMATION HEREIN WILL GOVERN MY RELATIONSHIP AND THE RELATIONSHIP OF ANY PARTICIPANTS WITH PREMIER PEDIATRIC THERAPY SOURCE. MY ACCEPTANCE HERE SUPERSEDES ANY OTHER AGREEMENT, WRITTEN OR ORAL, THAT MAY HAVE BEEN PRESENTED TO ME WITH RESPECT TO MY RELATIONSHIP WITH PREMIER PEDIATRIC THERAPY SOURCE.
First and Last Name of Child Participant*
Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian Name*
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Adult Participant Name(if different from above)
Adult Participant Name Signature

Clear

Connection Crew Photo Release Consent
I understand that photographs or videos may occasionally be taken during the Connection Crew Social Skills Group and may be used for Premier Pediatric Therapy Source (PPTS) marketing purposes to promote the Connection Crew group or other services provided by PPTS, through print material, the practice website, social media, promotions, video and/or other advertising.

I understand that I can choose to not have my child photographed and it will not prevent my child from participating in the Connection Crew social skills group.

I further understand I can revoke my authorization for the above uses at any time by sending a written notice to Premier Pediatric Therapy Source: 6715 Little River Turnpike, Suite 200, Annandale, VA 22003.

Please initial ONE (1) preference and sign below.
I grant permission and consent for my child to be photographed during Connection Crew and release all rights related to said photographs.
I request that photographs NOT be taken of my child during Connection Crew
Name of Parent/Legal Guardian*

First NameLast Name
Child Participant Name

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Payment Form

Connection Crew Social Skills Group

$440.00 How many children will be participating

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

To download a copy of the registration, waiver and photo release forms click the "Preview PDF" button or download after submission of this form.

Thank You!
Should be Empty:

Participant Information

Emergency Contact Information

Connection Crew Social Skills Group Participant Waiver

Connection Crew Photo Release Consent

Payment Form