Children Playing Hours Form

Name

First NameLast Name

Age

Grade

School

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies? If so, please list

Does this child frequently place non-food items in their mouth?

Is this child able to engage appropriately with peers?

Will this child need an aide/adult support with them throughout the session in order to participate?

NOTE: A 1:1 aide will NOT be provided for the child, but is welcome if a child will need one. If so, please include the name of the adult that will be attending with the child.

Name

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Comments

Parental Consent for Child Participation

I hereby give permission for my child, listed in this submission form, to participate in the Occupational Therapy Fall Fine Motor workshop organized by FeedForward Occupational Therapy, LLC. I understand that the workshop is designed to support developmental, motor, sensory, and/or functional skills through age-appropriate activities facilitated by a qualified professional. I acknowledge that all reasonable precautions will be taken to ensure my child's safety and well-being during the workshop. I understand that my child should arrive to the workshop on time and will get picked up at the facility no later than 5PM. I understand that participation is voluntary and I may withdraw my consent at any time by notifying the organizer in writing. I agree that FeedForward Occupational Therapy, LLC, its staff, and affiliates are not liable for any injury, loss, or damage that may occur during or as a result of my child's participation in the workshop. By submitting this form, I confirm that I have read and understood the information provided, and I give my informed consent for my child to take part in the workshop.

OT Fall Fine Motor Workshop

Child Information

Parent Information