My Mind Matters Therapy Registration

Name*

First NameLast Name

Birth Date*

MonthDayYear

Parents E-mail*

example@example.com

Address*

Street Address

CityState / Province

Postal / Zip Code

Mobile Number*

Format: (000) 000-0000.

Emergency Phone Number*

Format: (000) 000-0000.

Please advise of any food or drink allergies*

Need to take any medication?*

Participants NDIS Number

Plan Managers E-mail for billing:

example@example.com

NDIS or Private*

Self Managed or Plan Managed

Any information we need to know about your child.*

Terms & Conditions -Social Group participants must give My Mind Matters Therapy a minimum of 2 business days notice of non attendance; and if notice is not provided within time, cancellation policy will apply as per NDIS price guidelines. My Mind Matters Therapy (MMMT) accepts no responsibility for any loss of, or damage to, personal property whilst attending, or participating in, any Social Groups. MMMT and its staff accept no responsibility for any injury, death, loss or damage to any person occurring out of, or in relation to Social Groups. Parents/Guardians are aware of, and fully understand, the risks associated with group activities and acknowledge that their child/children participate at their own risk and shall indemnify My Mind Matters Therapy and its staff against all actions, suits, proceedings, demands, costs and expenses which may be taken or made agains My Mind Matters Therapy. If a Parent/Guardian of a participant is unable to be contacted, or it is otherwise impractical for the Parent/Guardian to be contacted, MMMT and its staff are authorised to: Consent to a participant receiving medical or dental treatment from a medical practitioner in the event of an illness or accident administer or consent to such first aid as MMMT and its staff may consider to be reasonably necessary in the case of illness or injury. Parents and Guardians acknowledge and accept all risk involved in the administration of any medical or dental treatment or first aid considered to be reasonably necessary and the responsibility of payments of all expenses incurred in relation to such treatment or aid including, but not limited to, any emergency transportation required. Parents/ Guardians must disclose to MMMT any medical condition that their children participating in Social Groups have on the application form. This information will be kept strictly confidential and MMMT and its staff unless required to be disclosed for treatment or aid purposes.MMMT requires 2 business days notice for cancellation or full fee will be charged. Children can bring their own snack and drink. MMMT has a strict no-nut policy. Children will receive drinks and snacks at the Social group.*

Yes

TRANSFER OF IMAGE RIGHTS FOR MINORS I declare: That I have been duly informed by the organiser that during the Activities, the organiser itself or third parties with its authorisation will be able to record, take photographic images, audio-visual and/or sound recordings and file for the sole use of MY MIND MATTERS THERAPY. That I hereby accept and authorise the organiser to record the image of the Minor (including image, voice and name), and to authorise third parties to record such image, through any audio, photographic and/or audio-visual medium, while they are attending, participating in and/or watching the activities. That I give my voluntary consent and, therefore, I expressly authorise the organiser to use it for its own purposes or through transfers to third parties, for an indefinite period, all or part of the contents recorded or captured during the activities for MY MIND MATTERS THERAPY, including for the use of the Application and/or website (whether directly by the organiser or by third parties with its authorisation), in which the image, name and/or voice of the minor appears, either individually or collectively, for advertising, promotional and informative purposes of MY MIND MATTERS THERAPY and, in particular, including among others (for illustrative and not limitative purposes), the use through internet (websites ,Application, social media, and others), TV, exhibition and public communication in exhibitions or media to for the use and to promote MY MIND MATTERS THERAPY. I accept that this authorisation and the right for use and exploit derived from the same are free of charge, so I expressly waive rights to any compensation arising from the transfer of the rights set forth herein, and I agree not to claim any remuneration, payment, fee and/or compensation in the future. That I acknowledge and accept that the media, files, content and advertising and promotional assets here referred to in which the image of the Minor may appear are and will be owned by the organiser. I authorise the organiser to keep the Minor’s data as long as I have not communicated my desire for the organiser to stop doing so. For all the above, I sign freely, consciously, and voluntarily this transfer of the Minor’s image rights document, accordingly, for all purposes and without reservation.*

YesNo

My Mind Matters Therapy Registration Form- Art Group.