Thanksgiving Therapeutic Day Program

Thanksgiving Therapeutic Day Program

Interest form
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
School Name*
Grade*
Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Work Number*
Email*
Occupation/Employer
Emergency Contact Information-Alternate Pick-Release
Emergency Contact #1
Name*

First NameLast Name
Mobile Phone Number*
Work Phone
Email*
example@example.com
Relation to child*
Emergency Contact #2
Name*

First NameLast Name
Mobile Phone Number (must be different than primary number above)*
Work Phone
Email*
example@example.com
Relation to child*
Please list those people who are permitted to pick up your child*
Your child will not be released to anyone that is not listed above. Please contact us in advance for occasions where an individual not listed will be picking up your child.
Medical Release Information
Primary Physician*
Phone Number*
Hospital Preference*
Please list any medical conditions, including any that require maintenance medication (i.e. Diabetes, Asthma, Seizures). If medication needs to be administered while your child is at our day program, you will need to come to administer medication. No staff is allowed to administer medication. *
Is your child presently being treated for an injury or illness, or taking any form of medication for any reason? If your answer is yes, please explain:*
Is your child allergic to any type of food or medication?*
If yes, please explain:
Does your child have a diagnosis that will assist with program planning? If so, please explain:*
The purpose of the above listed information is to ensure that medical personnel have details of any medical condition which may intefere with or alter treatment.
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.
Parent's /Guardian Initials*
Does your child require one on one assistance at their school, ABA center, or daycare ?*
If yes, please explain:
Does your child require special accommodations? *
If yes, please explain. Also, please provide us with helpful information if your child becomes upset, such as calm down strategies used at home or school. Please put n/a if they do not require special accommodations.*
Is your child potty trained?*
If no, please explain current training status:
Does your child require a special diet?*
If yes, please explain:
Please provide us with helpful information if your child becomes upset, such as calm down strategies used at home or school. Also, please share any information that will be helpful for us to know in order to better understand your child. (i.e. they may cry when hungry, they crawl under a table when scared, they need hugs for comfort, they need a break from a noisy environment when holding their ears, etc.) *
Please describe to us how your child communicates. *
Please tell us about activities your child enjoys engaging in. *
Does your child react strongly to unexpected or loud noises (for example sirens, dogs barking, hair dyer.)*
Does your child display the need to touch people or objects more than peers of the same age? *
Does your child put objects in their mouth? ( for example, pencil, hands, etc)*
Is your child distressed by changing plans, routines, or expectations? Please explain. *
How did you hear about Therapeutic Learning Center Programs?*

WebsiteFlyerWord of mouthSchoolSocial MediaOther
I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and or webspace:*
Parent's /Guardian Initials*
Terms of Agreement

Therapeutic Learning Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded unless a child is unable to participate due to an accident or illness per physician orders.
Waiver

THERAPEUTIC LEARNING CENTER, LLC

PARENT

Permission Slip, Waiver of Liability, Indemnification, Medical Agreement

and Grant of Rights

Permission Slip

I, the parent/legal guardian of this participant, hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Thanksgiving Therapuetic Day Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgment of voluntary consent to allow my child to participate in this Program.

Waiver of Liability

My signature below indicates my understanding of the details of the Program. On behalf of my child, I voluntarily agree to accept any and all risks associated with their participation in the Program. On behalf of my child, I agree to forever indemnify, hold harmless, waive, and release TLC, its respective officers, members, employees, insurers, and representatives (“TLC Group”) thereof, from liability for any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have on my behalf or on behalf of my child, known or unknown, directly or indirectly, for any losses, damages, or injuries, including death, arising from, but not limited to, negligence, omissions, or fault, by or on behalf of TLC.

Indemnification

I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the Program.

Medical Agreement

If the participant has any special medical problems, allergies, dietary needs, handicaps, special prescriptions, etc., please list (and use additional sheets if necessary) I have explained them in the registration form above.

In case of an emergency, all attempts to reach me should be made to the telephone number(s) stated above on the registration form.

If any emergency medical procedures or treatments are required during the Program, I hereby consent to the staff of TLC’s Program, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter. My signature below also indicates that my child is in adequate physical condition to participate in the Program.

GRANT OF RIGHTS

I, Parent/Legal Guardian, grant TLC the right and license to use my child’s liken, photographs and other attributes (collectively, “Approved Attributes”) to promote and advertise TLC’s services in the media including TV, radio, print advertising, point-of-sale materials, promotional materials, grassroots marketing efforts, public relations efforts and the Internet (to include but not be limited to web banners, blogs and social networking sites).

Declaration

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, WAIVER OF LIABILITY, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

Severability

The Undersigned expressly agrees that the foregoing Release, Waiver and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.

READ BEFORE SIGNING
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Printed Name of Parent/Guardian*
Thanksgiving Therapeutic Program 2024

Due to our programs filling up very quickly, all children will enter under the status "waitlisted" until our Programs Administrator contacts you to confirm the days enrolled. You will also be contacted if the program is full and your child is placed on the waitlist. Please select the days you wish to enroll your child below. Full Days-$94 a day, Half Days - will be waitlisted.
Week 1 - November 25-27
Full Day, Monday, Nov. 25th: 9am-2:30pm

Yes
Full Day, Tuesday, Nov. 26th: 9am-2:30pm

Yes
Full Day, Wednesday, November 27th: 9am-2:30pm

Yes
Fall session payment is due by November 1st. The office will send you an invoice for payment. A $35 registration fee will be included in your invoice. Call 504-565-7300 or email programs@tlcnola.com with any questions!
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Date

MonthDayYear
Date
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Thanksgiving Therapeutic Day Program

Thanksgiving Therapeutic Program 2024

Week 1 - November 25-27