Kidz Connect Group Registration
Child's Name
*
First Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Age
Grade your child will be entering in fall 2025
Please Select
Preschool
Pre-K
Kindergarten
Pre-1st
1st
2nd
3rd
4th
5th
6th
7th
8th
Name of School
What are three things you would like for us to know about your child?
Please list any special accomodations your child may need
Any pertinent medical information (allergies, etc)
Parent/Guardian
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am a legal guardian:
Yes
No
Other
EMERGENCY CONTACT
Name
First Name
Last Name
Patient Relation
Phone Number
Please enter a valid phone number.
How did you hear about the group?
CONSENT TO PARTICIPATE
I acknowledge the risks / potential risks of engaging in the group programs at Kidz Connect Therapy which are similar to the risks of play and activities of daily living. After considering the inherent risks, I feel that the possible benefits are greater than the possible risks. I voluntarily assume the risk for my child. I hereby as parent or legal guardian intending to be legally bound, for myself, my heirs and assignees, executors or administrators, waive and release forever any and all claims for damages against Kidz Connect Therapy, LLC., its therapists, volunteer employees, referring entities, subcontractors, property owners upon whose land the services are conducted, for any and all injuries and / or losses I or my child may sustain while voluntarily participating in the program. I understand that Kidz Connect Therapy, LLC wishes to take reasonable steps to maintain the safety and well being of its participants. I confirm that I have disclosed all medical conditions of my child that may be affected in any way by the treatment. I acknowledge that I am responsible for updating this release if any medical conditions of my child change. I acknowledge that I have been given sufficient time to ask questions, if any, concerning the nature and scope of this agreement. I understand that this waiver will also include any additional attendees (siblings, friends, etc).
*
(please type name here)
I give permission for the therapists/group leaders to take my child to the restroom: (please note, if your child is not potty trained you must be present for entire group)
*
Yes
No
MEDIA RELEASE
Please note in the field below if you give permission or do not give permission for your child to participate in photos and/or videos for media/marketing purposes by Kidz Connect Therapy LLC. Your child’s first name, photo, and/or video may be used and seen in printed marketing materials, website content, and/or our Facebook business page. Media will not be shared with any third parties. This release will remain active until I notify Kidz Connect Therapy LLC
*
Yes
No
Signature
*
I would like to register my child for the following group(s):
*
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2-3 year olds 9:00-9:45 Social Group
Fun and creative social group with focus on peer play, fine motor craft activity, gross motor play, sensory play, speech and language advancement, etc. July 28th 9-9:45
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
3-6 year olds 10:00-10:45 Social Group
Fun and creative social group with focus on peer play, fine motor craft activity, gross motor play, sensory play, speech and language development etc. July 28th 10-10:45
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
6-9 year olds 11:00-11:45 Social Group
Fun and creative social group with focus on peer play, fine motor craft activity, gross motor play, sensory play, speech and language development, etc. July 28th 11-11:45
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
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