Group Learning Program Registration

I would like to register for (Control-click or Command-click to select multiple programs):













    YesNo

    YesNo

    YesNo

    Additional Information

    All below boxes must be checked to submit form.

    By checking this box you are digitally signing this form and agree that the above information is true and complete to the best of your knowledge.
    I release Pathways Pediatric Services from any liability in connection with medical treatment and unavoidable accidents.
    Pathways Pediatric Services has my permission to use necessary medical measures in the event of an emergency.
    I consent to my child participating in group learning.
    I consent to my child receiving individual and/or group therapy by a Pathways Speech-Language Pathologist, Occupational Therapist, Therapy Assistant or Student Clinician.

     

    YesNo

    Payment must be made at the time of registration.
    E-transfer & cheques accepted.
    info@pathwayspediatrics.ca
    Thank you for your submission & have a fun day!

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