8-Week Summer Articulation Group

8-Week Summer Articulation Program

Grades K-3: Tuesdays (6/24-8/12) at 11:30 am
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Does your child currently receive speech therapy?*

YesNo
What speech sounds does your child have difficulty saying?*

PBMWTDKGNNGFVHYSZSHCHJLTHR
Parent/Caregiver Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Additional Parent/Caregiver Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Where did you hear about us?*
Any special message you need us to know
I hereby grant permission for my child to participate in the Liberty Speech Associates Summer Articulation Program. I understand and acknowledge that the program fee is non-refundable.

I agree that a parent or designated caregiver will remain on the premises (e.g., in the waiting room or parking lot) for the duration of each session.

I acknowledge that this program is designed for enrichment purposes only and is not considered medically necessary. As such, services provided through this program are not billable to or covered by health insurance.

I understand that make-up sessions will only be provided in the event that Liberty Speech Associates must cancel a session. Make-up sessions will not be offered for participant absences due to scheduling conflicts, illness, or other personal reasons.

I voluntarily waive and release any and all claims for damages against Liberty Speech Associates, LLC, including its employees, representatives, and agents, for any injuries or incidents that may occur while my child is participating in the program.

I understand that a graduate student intern, under the supervision of a licensed speech-language pathologist, may assist in facilitating the program.

I provide consent for Liberty Speech Associates to use any photographs taken during the program for future promotional materials, including brochures, website content, and social media platforms.
Name of Person Completing this Form*

First NameLast Name
Relationship to Child*
Signature*

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Submit your non-refundable payment below:*

FULL PAYMENT Grades K-3: Tuesdays (6/24-8/12) at 11:30 amThis payment will be applied to the full 8-week program. This payment is non-refundable. No additional payment is required for participation in the 8-week program.

$225.00 Quantity

DROP-IN PAYMENT Grades K-3: Tuesdays (6/24-8/12) at 11:30 amThis payment will be applied to your child's first drop-in visit during the program. This payment is non-refundable. All future drop-in visits must be paid on the date of attendance.

$30.00 Quantity

Total

$0.00

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8-Week Summer Articulation Program

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