FFTC Social Group Enrollment Form
Child's Name
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Child's Gender
Please Select
Boy
Girl
Other
Parent/Guardian Full Name
First Name
Last Name
Primary Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Daily Living Skills Questionnaire
Please select the answer that best describes your child’s abilities
Is your child toilet trained?
*
Yes, fully independent
Needs assistance
Not yet toilet trained
Does your child follow basic directions (e.g., “Come here,” “Sit down”)?
*
Yes, consistently
Sometimes
No, rarely follows directions
How often does your child attempt to leave or elope from a designated area?
*
Never
Occasionally
Frequently
Does your child demonstrate safe and appropriate behavior toward other children (e.g., non-aggressive)?
*
Yes, rarely or never aggressive
Sometimes
Often shows aggression
How would you rate your child’s ability to function independently in a small group?
*
Very independent
Needs occasional support
Needs constant support
Does your child have any specific behaviors or needs that staff should be aware of to ensure their safety and participation? (If you choose Yes, please specify in the column)
*
No
Yes
Please list any diagnoses your child has that we should know about.
*
Back
Next
Photo and Video Consent
During social group sessions, your child may be photographed or videoed for marketing purposes. These materials may be used to promote our programs on social media, our website, or other promotional platforms. Please check below to indicate your acknowledgment and understanding of this policy:
I understand that my child may be photographed or videoed during social group sessions for marketing purposes.
Attendance and Refund Policy
Missed Sessions:
Firefly Therapy Clinic’s social groups are structured to benefit from consistent attendance. Please note that no make-up sessions are provided for any missed group sessions, regardless of the reason for absence and no refund will be given.
Illness or Inconsolable Behavior During Group:
If a child becomes ill or inconsolable during a session, Firefly Therapy Clinic staff will contact the parent/guardian to pick up the child. No refunds will be issued for any portion of the session if early pick-up is necessary.
Acknowledgement of Risk
In consideration of the services of Firefly Therapy Clinic their officers, agents, employees, and stockholders, and all other persons or entities associated with those businesses (hereafter collectively referred to as “FFTC”) I agree as follows: Although FFTC has taken reasonable steps to provide me with appropriate equipment and skilled guides so I can enjoy an activity for which I may not be skilled, FFTC has informed me this activity is not without risk. Certain risks are inherent in each activity and cannot be eliminated without destroying the unique character of the activity. These inherent risks are some of the same elements that contribute to the unique character of this activity and can be the cause of loss or damage to my equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. FFTC does not want to frighten me or reduce my enthusiasm for this activity, but believes it is important for me to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks. The hazards of walking on uneven terrain, slips and falls; slipping and falling on the rock wall, crashing on trampoline, falling from the swing, being hit by a ball or toy, falling from a chair, choking, allergic reaction; my own physical condition and the physical exertion associated with these activities. I am aware that FFTC entails risks of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different from other activities and that I have responsibilities as a participant. I acknowledge that the staff of FFTC has been available to more fully explain to me the nature and physical demands of this activity and the inherent risks, hazards, and dangers associated with this activity. I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read, clearly understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representative, and estate and for all members of my family, including minor children.
I, as the legal parent or guardian of the patient herby give permission for the patient to participate in the activity and further agree, individually and on behalf of the patient to the above terms. By signing this box, I acknowledge that I have read and understand the terms of this document.
*
Please check off the products
prev
next
( X )
Social Group Buddy Bees (Ages 3-4)
COMING SOON
$
350.00
Quantity
1
Social Group Friendly Fireflies (Ages 5-8)
6-Weeks - February 18th, 2025. (Tuesdays 5:30pm-7:00pm) ***TOTAL IS $350. $175.00 is due at sign up. The other $175.00 will be due before the 3rd week.
$
175.00
Quantity
1
2
3
4
5
6
7
8
9
10
Social Group Chatty Caterpillars (Ages 9-12)
6-Weeks - February 18th, 2025. (Tuesdays 5:30pm-7:00pm) ***TOTAL IS $350. $175.00 is due at sign up. The other $175.00 will be due before the 3rd week.
$
175.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
ACH Bank Transfer
Submit
Submit
Should be Empty: