While Wings & Wonder Speech Therapy makes every reasonable effort to accommodate allergies and dietary restrictions, an allergen-free environment cannot be guaranteed and accidental cross-contact may occur.

If the parent decides to bring their own food, a list of foods that the group is exploring will be provided before the classes.

I authorize Wings & Wonder Speech Therapy and Kayla Madoff, M.S.Ed., CCC-SLP to administer my child's emergency medication in accordance with physician instructions if an emergency situation arises and emergency medical services (911) have been contacted when appropriate.

I understand that I am responsible for ensuring that all emergency medications are:

• Present at each session

• Clearly labeled

• Readily accessible

• Not expired

Little Bites Club is a feeding exploration group designed to support positive relationships with food, social engagement, communication, and feeding skill development.

• Participation is voluntary.

• Children are never forced, pressured, bribed, or required to eat any food.

• Looking, touching, smelling, licking, tasting, and eating foods are all considered meaningful participation.

• Group activities may include food exploration, food crafts, sensory play, communication activities, and social interaction.

• Individual outcomes cannot be guaranteed.

I understand that participation may involve risks including:

• Choking

• Gagging

• Allergic reactions

• Food-related injuries

• Exposure to environmental factors including insects, pollen, ticks, weather conditions, and outdoor terrain at Pleasant Valley Lavender.

I voluntarily assume these risks and agree to release and hold harmless Wings & Wonder Speech Therapy, Kayla Madoff, M.S.Ed., CCC-SLP, and Pleasant Valley Lavender except in cases of gross negligence or willful misconduct.

• Respect the privacy of all participating children and families.

• Refrain from sharing personal information about other participants.

• No photograph, video record, or livestream other children without permission.

• Maintain respectful interactions within the group setting.

I understand that confidentiality cannot be guaranteed within a group environment.

Wings & Wonder Speech Therapy is committed to protecting the privacy and confidentiality of your child's protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state laws.

Protected health information may include information related to your child's medical history, evaluations, therapy services, treatment recommendations, progress notes, billing records, and other information necessary to provide quality care and services.

As a parent or legal guardian, you have certain rights regarding your child's protected health information, including the right to:

Receive a copy of the Notice of Privacy Practices
Request access to your child's records
Request corrections to information you believe is inaccurate or incomplete
Request restrictions on certain uses or disclosures of information
Request confidential communication methods when appropriate
Receive an accounting of certain disclosures of protected health information
File a complaint if you believe your privacy rights have been violated
Wings & Wonder Speech Therapy may use and disclose protected health information as permitted by law for purposes including:

Treatment and coordination of care
Payment for services rendered
Healthcare operations and practice management
Situations required by federal or state law
Emergencies involving the health or safety of the child or others
Reasonable safeguards are maintained to protect the privacy and security of all protected health information. However, no method of electronic communication can be guaranteed to be completely secure.

By signing below, I acknowledge that:

I have received, reviewed, or have been offered access to the Wings & Wonder Speech Therapy Notice of Privacy Practices.
I understand my rights regarding protected health information under HIPAA.
I understand how my child's health information may be used and disclosed for treatment, payment, healthcare operations, and other legally permitted purposes.
I understand that I may request a copy of the Notice of Privacy Practices at any time.

I understand that my child's name will not be published without additional written permission.

Registration is required in advance.

• Drop-In Sessions are $40 per session.

• 4-Week Passes are $120.

• Registration fees are non-refundable except as outlined in the illness, weather, and therapist cancellation policies.

• Make-up opportunities may be offered based on availability.

By signing below, I acknowledge that I have read and understand all policies, disclosures, and consent information contained within this registration.

REGISTRATION ACKNOWLEDGEMENT

• Registration is considered complete once all required paperwork and payment have been received.

• Registration is required in advance.

• Spaces are limited and available on a first-come, first-served basis.

• Fees are non-refundable except as outlined in the illness, weather, and therapist cancellation policies.

***Please Note: The Child Feeding History & Family Goals Questionnaire will be provided via email after registration, payment, and session date selection have been completed. A comprehensive Little Bites Club Parent Packet, including all program information, policies, consent documents, and resources, will also be emailed to you for your records. Following registration, Kayla Madoff, M.S.Ed., CCC-SLP will contact you directly via email to confirm your child's enrollment, answer any questions, and discuss any feeding, allergy, or participation concerns prior to the start of the group.***

By signing below, I acknowledge that all information provided is accurate and that I have read and agree to the policies, waivers, disclosures, and consent forms contained within this registration packet.