Preschool Prep Registration Form

Preschool Prep Registration Form

Groups start the week of June 8th on Mondays/ Wednesday/ Fridays 10:00am-12:00pm. This will be a reoccurring and drop in group so please specify date range below. Rates are as follows: $45 (current client at clinic) $50 per session
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have any allergies?*

No known allergiesFood allergiesMedication allergiesEnvironmental allergiesOther
Please list and describe any allergies your child has.
Is there anything else we should know about your child?
Days attending

MondayWednesdayFriday
Please write specific dates or range you would like to sign your child up!
Pay Via:
I understand the door of the sensory gym has a lock for the safety of my child. We do not wantthe children running on equipment when we are with another child as well as strangers enteringthe building. I understand that the code to the door will not be shared with parents.SAFETY AND PHYSICAL CONTACTPediatric Therapy of South Jersey and all Therapists assure to the best of their ability that your child is kept safe in the office. If a child should engage in behaviors dangerous to her/himself or therapists during a session and cannot stop these behaviors independently, Therapist can cancel the sessions at any time with payment still provided. In addition, in the course of assessment or treatment, young children sometimes seek physical contact with the therapist in the form of hugs.Pediatric Therapy of South Jersey assures that any physical contact is positive and safe due to sensory seeking behaviors. Parents are encouraged to contact the Therapist whenever they havequestions about their child’s treatment.CONSENT FOR PARTICIPATION WITH THERAPEUTIC EQUIPMENTIntervention programs usually involve the use of specialized equipment such as various swings,bolsters, inflated therapy balls, climbing structures, tactile media (such as soap foam, Play-Doh,and lotion), and a variety of other activities that involve fine, gross, and oral motor coordination.Therapy activities often involve encouraging the child to try new things in order to foster increasedskills and abilities. While staff make great efforts to ensure each child's safety, the nature of thetherapeutic intervention includes the risk of injury in falling and bumping into otherpeople/equipment. I am aware of the inherent risk of this type of activity and I give permission for my child to participate in therapy as described.Signature
EMERGENCY MEDICAL RELEASEIn the event medical attention is required for your child while on the premises, we need your authorizationto implement treatment. Please read and sign the statement below.I give my permission for Pediatric Therapy of South Jersey to contact emergency personnel in the event of a medical emergency.
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