*Building Blocks*

Name

First NameLast Name

Date of birth

Date

Gender

Primary Phone Number

Format: (000) 000-0000.

School Name

Grade

Parent/Guardian

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone Number

Format: (000) 000-0000.

Email

Occupation/Employer

Emergency Contact Information-Alternate Pick-Release

Emergency Contact #1

Name

First NameLast Name

Mobile Phone Number (Primary)

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Email

example@example.com

Relation to child

Emergency Contact #2

Name

First NameLast Name

Mobile Phone Number (must be different than primary number above)

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Email

example@example.com

Relation to child

Your child will not be released to anyone that is not listed below. Please contact us in advance for occasions where an individual not listed will be picking up your child.

Please list those people who are permitted to pick up your child

The purpose of the below-listed information is to ensure that medical personnel have details of any medical condition which may interfere with or alter treatment.

Medical Release Information

Insurance information

Name of Health Insurance

Policy Number

Primary Physician

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Hospital Preference

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

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 the program, you will need to come to the program 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 currently receiving therapeutic services? (i.e. occupational therapy, speech therapy, physical therapy, play therapy.) If yes, please explain.

Does/did your child receive Early Steps services?

Can you provide us with contact information and do we have permission to contact Early Steps?

If you answered yes to the above questions please provide information here:

Please list any foods, medications, etc. your child is allergic to?

Does your child require individualized, one-on-one support from an adult throughout the day at their school, ABA center, or daycare—for tasks such as staying on task, managing behaviors, following directions, or remaining safe?

If answered YES, please explain:

Has your child been given any diagnoses that could help us better support them in our program? If so, please describe:

Is your child potty trained?

If no, please explain current training status:

Does your child require a special diet?

If yes, please explain:

Please share any helpful information about how your child expresses distress and what strategies are effective in helping them calm down—such as techniques used at home or school. Additionally, let us know anything else that would help us better understand and support your child. For example: they may cry when hungry, crawl under a table when scared, seek hugs for comfort, or need quiet breaks when covering their ears.

How does your child typically communicate their needs, wants, or feelings? (For example: talking, pointing, using a device, gestures, etc.)

Please tell us what activities your child enjoys engaging in.

Does your child seem to not hear you when you call their name? (even though hearing is ok)

Does your child display the need to touch people or objects more than peers of the same age?

Does your child pursue movement to the point where it interferes with daily routines? (for example, can't sit still, fidgets, etc.)

Does your child put objects in their mouth? (for example, pencil, hands, etc)

Is your child distressed by changes in plans, routines, or expectations? Please explain.

How often can your child focus and attend to a task that is non preferred? (For example, some children don't enjoy sitting at a table to draw or when asked to clean up their toys.)

When your child plays with toys, does he/she use them in a variety of different ways or do they have specific way they play with the toy that is non purposeful? Please explain.

What is the main goal or reason for your child to attend TLC's Building Blocks Program?

Signature

How did you hear about Therapeutic Learning Center Programs?

Terms of Agreement

The 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”) 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 acknowledgement 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, handicap, 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, grass roots 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

Initials

I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and or webspace:

SUPPORT POLICY

We truly value supporting your child during our seasonal programs. In an effort to ensure that we are equipped to help your child, despite ability, thrive in our seasonal programs we want to offer clarity regarding our ability to provide 1:1 attention to your child. Our seasonal programs are led by skilled therapists who are trained to handle a range of different abilities. We are able to offer emotional regulation support, improve peer to peer relations, improve play based skills and improve sustained attention during fun, seasonal themed fine and gross motor tasks.

Our programs offer a smaller staff to child ratio than a traditional day program offers. Our staffing consists of 1-2 therapists and 2-3 technicians to support your child. Although we have a smaller staff to child ratio, we are unable to accommodate children who require frequent 1:1 support due to but not limited to the following:

Biting peers or staff (See our aggression policy)
Elopement from staff and other children in seasonal programs.
The need to be separated from the group for extended periods of time due to emotional regulation difficulties or negative behaviors impacting the safety of your child, the other children, and our staff.
Inability to engage or participate in a schedule with other children.

We want to ensure that your child is safe, cared for, and involved in an engaging environment during our seasonal programs.

BEHAVIOR/AGGRESSION POLICY

We understand that many children have behavioral challenges and benefit from a therapeutic environment; however, if we determine the behaviors are outside of our scope of practice, we may recommend outside services or providers that can help those children with aggressive behaviors. You may be asked to pick up your child for an aggressive incident that is dangerous for the other children or staff. If your child has aggressive tendencies or demonstrates 3 or more aggressive behaviors toward other children or staff members while attending our program, we may recommend your child’s attendance to our program be placed on hold until other service providers are involved. Examples of these behaviors could include excessive biting, unprovoked aggression toward other children, or an excessive flight risk that would warrant one-on-one attention, etc. Refunds are not given in these instances.

We understand that some children benefit from having one-on-one support to succeed. Suppose it is discovered that your child needs more support than our program can provide. In that case, we will recommend your child be placed in an alternative TLC program that will better meet their needs, discontinue enrollment, and/or suggest other services with outside providers to ensure the child's success.

Please acknowledge an understanding our support/behavior policy.

Therapeutic Day Programs Parent Information

Welcome to Therapeutic Learning Center! We are excited to partner with your family as your child embarks on a journey of growth, learning, and discovery.

Our Therapeutic Day Program provides a structured, nurturing environment designed to support each child's social, emotional, communication, sensory, physical, and cognitive development. Through individualized support, therapeutic interventions, purposeful play, and meaningful peer interactions, our goal is to help every child build confidence, independence, and lifelong skills.

Our program offers individualized support through small therapist-to-child ratios, individual and group therapeutic interventions, social-emotional skill development, sensory-rich learning experiences, art, music, movement, and play-based activities, positive behavior supports, and individualized learning opportunities designed to help each child reach their fullest potential.

To ensure a safe, supportive, and successful experience for every child, we have established the following policies and procedures. These guidelines allow us to provide consistent, high-quality care while fostering a positive environment for all participants.

Thank you for trusting Therapeutic Learning Center. We look forward to supporting your child's growth every step of the way.

Late Arrival & Pick-Up Policy
To ensure a smooth transition to our afternoon outpatient therapy schedule, children must be picked up no later than 11:55 a.m. (morning program) or 2:25 p.m. (afternoon program).

A $25 late fee will be assessed for pickups after 12:00 p.m. or 2:30 p.m. In addition, a fee of $1 per minute will be charged for every minute beyond these times.

Repeated late pickups disrupt clinic operations. After the third late pickup, Therapeutic Learning Center reserves the right to discontinue your child's enrollment in the program.

Illness Policy
For the health and safety of all children, please do not bring your child to TLC if they are ill. Children who arrive with symptoms of illness—including fever, vomiting, diarrhea, pink eye, excessive coughing, or a contagious rash—will not be permitted to attend.

Children may return after being symptom-free for at least 24 hours without medication, including fever, vomiting, diarrhea, or a contagious rash.

If your child develops a fever of 100.4°F or higher, vomiting, or diarrhea while attending the program, a parent or guardian will be contacted immediately for pick-up.

If your child will be absent due to illness, please notify us through Brightwheel, by emailing programs@tlcnola.com, or by calling 504-565-7300.

Tuition is based on enrollment rather than attendance; refunds, credits, or make-up days are not provided for illness-related absences.

Absence & Vacation Policy
Tuition reserves your child's place in the program. Refunds, credits, or make-up days are not provided for planned or unplanned absences, vacations, illnesses, late arrivals, or early departures.

Holiday & Weather Closure Policy
Therapeutic Learning Center is closed in observance of New Year's Day, Mardi Gras Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day. Tuition is based on enrollment rather than attendance; therefore, credits or refunds are not provided for scheduled holiday closures.

For the safety of our families and staff, TLC may close due to severe weather or other emergencies. Refunds or credits are not provided for unexpected weather-related closures.

Consultation Services
Consultation services requested by parents with teachers, physicians, psychologists, or other professionals involved in a child's care are billed at $20 per 15-minute increment and are available after your child has attended at least four group sessions.

Trial Period
Every child begins the program with a 15-day trial period. During this time, our therapists determine whether the Therapeutic Day Program can safely and effectively meet your child's therapeutic needs while maintaining a successful learning environment for all participants.

If additional support is recommended, options may include transitioning to half-day attendance, temporarily pausing participation while additional services are obtained, increasing individual Occupational or Speech Therapy services, adding mental health services, or providing a one-on-one shadow during the program.

If our team determines the program cannot safely meet your child's needs, we will partner with your family to recommend the most appropriate next steps.

Enrollment
Enrollment is continuous and automatically renews each month unless written notice of withdrawal is received. Families do not need to re-register each month. When your child is ready to graduate from the program, your lead therapists will discuss recommendations and develop a transition plan with your family.

Invoices & Payment

Our Therapeutic Day Programs are billed as private pay only and are not billed through insurance.

Tuition is based on your child's scheduled attendance for the upcoming month according to the enrollment option selected (2-day, 3-day, 4-day, or 5-day). Invoices are issued through Brightwheel approximately one week before the upcoming month of attendance unless your child is enrolled with immediate availability.

Tuition is due by the first day of the month in which your child attends. All payments must be made electronically through Brightwheel.

Please add support@mybrightwheel.com to your trusted contacts to ensure you receive your monthly invoice.

A $25 late fee will be assessed for any payment not received by the due date. If tuition remains unpaid after the due date, a valid credit card will be required to remain on file. Outstanding tuition and applicable late fees may be charged to the card on file. Failure to provide a valid payment method may result in your child's enrollment being placed on hold and the reserved spot being offered to another family on the waitlist.

Families are strongly encouraged to enroll in Brightwheel Autopay.

Questions may be directed to programs@tlcnola.com.

Emergency Procedures
In the event of a personal emergency affecting pick-up arrangements, please notify our office immediately at 504-565-7300. If someone other than an authorized individual will be picking up your child, please notify TLC in advance. Children will only be released to individuals listed on the authorized pick-up form, and identification may be required. For weather-related emergencies requiring an early dismissal, families will be contacted immediately.

Separated or Divorced Parents Policy
Therapeutic Learning Center is committed to providing the best possible care for every child. We believe children experience the greatest success when parents work collaboratively with one another and with our therapy team.

Brightwheel serves as the primary communication platform so both parents have equal access to program updates. Upon request, emails may be sent to both parents.

Immediate feedback regarding a child's day will be provided to the parent or guardian present at pick-up. Parents wishing to discuss progress in greater detail may schedule a consultation.

Parents are encouraged to communicate respectfully, collaborate regarding therapeutic decisions, attend meetings together whenever possible, and prioritize their child's therapeutic progress above personal disagreements. Therapists remain neutral professionals focused on the child's success.

Graduation
Graduation occurs when the therapy team and family mutually agree that the child's goals have been achieved and the program is no longer therapeutically necessary. If graduation occurs during the middle of a month, tuition will be prorated for any remaining scheduled program days. Families will be included in all transition planning.

Administrative Discharge
TLC reserves the right to discontinue enrollment when continued participation is no longer safe or appropriate due to safety concerns, repeated aggressive behaviors requiring additional evaluation, excessive late pick-ups, non-payment of tuition, or failure to comply with handbook policies. If aggressive behaviors occur on three occasions, TLC may require a psychological evaluation before determining continued participation.

Parent Withdrawal
Families wishing to withdraw must provide two weeks' written notice by emailing programs@tlcnola.com. Families remain financially responsible for tuition during the required notice period regardless of attendance. Verbal notification does not constitute official withdrawal.

Please acknowledge an understanding our policies.

Printed Name of Parent/Guardian

Date

PLEASE INITIAL BELOW: (1) I understand that my child will need to attend a trial day to determine if he/she can be supported by TLC Day Programs. (2) If my child is not able to be adequately supported by TLC Day programs, there will be alternate recommendations for providers that can be helpful. (3) I understand that Brightwheel will be the program used to send invoices and receive payments for my child. (4) I understand that I am required to submit a credit card on file to be used if my invoices are overdue. (5) I understand that due to the nature of this program being therapeutic, my child's placement will be determined by the Programs Director.