Screening Registration: Tigers & Tots Indoor Playground

Screening Registration: Tigers & Tots Indoor Playground
Child Full Name:

First NameLast Name
Preferred Name:
Age:
Date of Birth:

MonthDayYear
Date
Gender:
Parent/Guardian 1 Full Name:

First NameLast Name
Parent/Guardian 1 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Email:
example@example.com
Parent/Guardian 2 Full Name:

First NameLast Name
Parent/Guardian 2 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Email:
example@example.com

WAIVER OF LIABILITY, INDEMNIFICATION, AND MEDICAL RELEASE

I am aware of the dangers and the risks to myself, my child, and/or any child whose care I have been entrusted with, that is posed by the Tigers & Tots Indoor Playground, the LSU Health Sciences Center New Orleans School of Allied Health Professions Indoor Playground area for children ages 0-3 to our persons and property.

I understand that activity by myself, my child, and/or any child whose care I have been entrusted with involves certain risks for physical injury, including, but not limited to: running, climbing, playing, sliding, and other forms of mild to mid activities.

I also understand that there are potential risks to myself, my child, and/or any child whose care I have been entrusted with of which I may not presently be aware. Because of the dangers of participating in this activity, I recognize the importance and agree to fully comply with the applicable laws, policies, rules, and regulations and any supervisor’s instructions regarding participation in this activity.

I understand that LSU Health New Orleans does not insure participants in the above-described activity, that any coverage would be through personal insurance, and LSU Health New Orleans has no responsibility or liability for injury resulting from this activity.

I voluntarily elect to participate in this activity with the knowledge of the danger involved, and I hereby agree to accept and assume any and all risks of property damage or, personal injury to myself, my child, and/or any child whose care I have been entrusted with.

Waiver of Liability and Indemnification:

In consideration for being allowed to voluntarily participate in the above-referenced activity, on behalf of myself, my child, and/or any child whose care I have been entrusted with, I forever:

a) waive, release, and discharge LSU Health New Orleans and its agencies, officers, and employees from any and all negligence and liability for death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and

b) agree to defend, indemnify, and hold harmless LSU Health New Orleans, its agencies, officers and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participant’s actions during this activity or event.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.

I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

READ BEFORE SIGNING
PARENT/GUARDIAN SIGNATURE
Date

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship if Not Patient (legal documentation proving relationship by the signing individual may be required):

Other
I, {parentguardian1}, hereby grant permission to
LSU Health Sciences Center New Orleans to photograph, video tape,
record, or interview me, or in the case of a minor, my
child {childFull}, for print, broadcast, digital,
or social media use, for use in LSU Health Sciences Center New Orleans
publications, advertising or promotion, video or audio tapes, brochures,
website, social media, conferences, or for use in teaching by LSU Health
Sciences Center New Orleans faculty.

I hereby transfer to LSU Health Sciences Center New Orleans all rights
and claims I have, or in the future may acquire, with respect to such
photographs, video recordings, audio recordings, and/or written materials,
agreeing that same shall be the sole and absolute property of LSU Health
Sciences Center New Orleans. I hereby relieve and release LSU Health
Sciences Center New Orleans from any and all claims whatsoever, and for
any and all kinds of remuneration for use of such materials.
Signature
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
After submission, an email will be sent to book a play date.
Should be Empty:

Screening Type	Tympanometry & Otoacoustic Emissions Screening
Clinic	Hearing and Balance Clinic
Description	This screening checks how well your child's eardrum is moving and can help identify signs of fluid in the ear or an ear infection.It also checks how well the inner ear is working and helps screen your child's hearing. The screening is painless, non-invasive, and usually takes about 15 minutes to complete.

Screening Type	Sensory Profile 2 Screening
Clinic	Occupational Therapy Clinic
Description	The Sensory Profile 2 (SP-2) is a parent questionnaire that helps identify how your child reacts to everyday experiences like sounds, movement, touch, and busy environments. The screening highlights strengths and areas that may affect daily activities, play, learning, and routines, and can help determine if additional support or a full occupational therapy evaluation may be beneficial. It typically takes about 20 minutes.

Screening Type	Speech and Language Screening
Clinic	Speech and Language Pathology Clinic
Description	This screening allows us to quickly assess your child's speech (making sounds correctly when they produce words) and language (how well they can express their thoughts and needs AND how well they understand others when they are spoken to). It typically takes about 15 minutes.

Screening Type	Pediatric Feeding Screening
Clinic	Speech and Language Pathology Clinic
Description	This screening allows us to quickly assess your child's oral motor skills, such as latching, sucking, swallowing, tongue movement , etc. needed for feeding. It typically takes about 15 minutes.

Screening Type	Strengths and Difficulties Questionnaire
Clinic	Child and Family Counseling Clinic
Description	Helps identify your child’s strengths as well as areas where they may need extra support. It looks at emotions, behavior, attention, friendships, and social skills. Parents and teachers can both share their observations, making it a helpful tool for understanding how a child is doing across settings.

Screening Type	ASQ:SE-2 Social-Emotional Screening
Clinic	Child and Family Counseling Clinic
Description	Helps identify how your child is developing socially and emotionally. It looks at skills such as managing emotions, communicating needs, interacting with others, and everyday behaviors.

Screening Type	ASQ-3 Developmental Screening
Clinic	Child and Family Counseling Clinic
Description	Checks whether your child is meeting developmental milestones expected for their age. It looks at communication, movement, hand and finger skills, problem-solving, and social skills.

Screening Type	M-CHAT-R/F Autism-Specific Screening
Clinic	Child and Family Counseling Clinic
Description	A screening tool that helps identify toddlers who may benefit from a closer look at their social communication, development, and learning. It can help determine whether additional evaluation for autism or other developmental differences may be helpful.

Screening Type	SWYC-Survey of Well-Being of Young Children
Clinic	Child and Family Counseling Clinic
Description	A comprehensive screening tool that provides a broad picture of your child’s development, behavior, and emotional well-being. It also includes questions about family and environmental factors that can affect a child’s growth and development.

Screening Type	Alberta Infant Motor Scale (Gross Motor Screening)
Clinic	Physical Therapy Clinic
Description	Screening for age-appropriate movement skills (rolling, crawling, walking, etc.), balance, posture, coordination, and mobility for children from 0-6 years old

Screening Registration: Tigers & Tots Indoor Playground

SCREENINGS