Parent Education Series

Parent Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Is your child currently receiving or has your child previously received any of the following therapies? (Select all that apply)*

If you selected "other" please explain below:

Child's date of birth:*

Gender:*

Is your child currently enrolled in school?*

If you selected yes, please list the school your child attends below:

Which sessions would you like to attend? (Select all that apply.) Sessions are $30 each.*

June 2nd- Emotional RegulationJune 16th- Sensory StrategiesJuly 7th- Potty TrainingJuly 14th- Picky EatingJuly 21st- Tips and tricks to improve fine motor sills/handwritingJuly 28th- How to help your child be successful in schoolAugust 4th- Recap, Q+A

Do you have any specific questions or topics you'd like us to address or add to the schedule?

How did you hear about our parent education series?*

I understand that the Parent Education Series is a group-based educational program and is not individual therapy services. I acknowledge that payment is required to reserve my spot in the series and is non-refundable. An invoice will be sent to the email provided on the first of each month for the sessions I have signed up for. I understand that I am responsible for full payment regardless of attendance and that missed sessions cannot be refunded or made up. I understand that this program is for educational purposes only and does not replace individualized evaluation or treatment. By signing below, I acknowledge that I have read and agree to the above policies.*

Waiver

THERAPEUTIC LEARNING CENTER, LLC

Waiver of Liability, Indemnification, Medical Agreement and Grant of Rights

Waiver of Liability

My signature below indicates my understanding of the details of the Group. On behalf of myself, I voluntarily agree to accept any and all risks associated with my participation in the Group. On behalf of myself, 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 myself 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 myself which may arise as a result of my participation in the Group.

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)

If any emergency medical procedures or treatments are required during the Group, 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 myself is in adequate physical condition to participate in the Group.

GRANT OF RIGHTS

I, grant TLC the right and license to use 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 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

Signature*

Date

Parent Education Series

Parent Education Series – Financial & Attendance Policy