Calgary Camp Registration - 4-5 Year Old Play and Language Group - Monday's September 12 to November 28 (Note: no class on October 10 or October 31) - Pathways Pediatrics

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Camp Registration – 4-5 Year Old Play and Language Group – Monday’s September 12 to November 28 (Note: no class on October 10 or October 31)Scott2022-09-13T13:05:12-06:00

Register

Camp Registration –
4-5 Year Old Play and Language Group
Monday’s, October 3 – December 19
(Note: no class on October 10 or October 31)

Select a camp *

Name of person completing this form *

First

Last

Referred by *

Child's name *

Date of birth *

Parent/Guardian Name(s) *

Primary phone *

Alternate phone

Email *

Full address *

Alternate contact name

Alternate contact phone

Has the child been seen by a Speech-Language Pathologist or Occupational Therapist? *

Yes
No

If yes, please list date and findings

Has the child been seen by other professionals? *

Yes
No

If yes, please list date and findings

My child has an aide at school and/or home? *

Yes
No

I consent to a Pathways team member contacting my child's teacher to obtain/release information

Yes
No

If yes, please list teacher's name and contact information (email and phone)

Additional information

Does your child have any allergies? *

Yes
No

If yes, please describe:

Please use this space to comment on any other information you feel is important (e.g., medical information, toileting, dietary needs)

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
I have read, understand and agree to the eligibility criteria (e.g., my child can sit and attend for a minimum of 5 minutes in a group setting)

I give Pathways Pediatric Services permission to utilize my child’s photograph or likeness in promotional materials. Names will not be published *

Yes
No

Payment

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!

Pathways Pediatrics Clinic

Calgary
#130, 7220 Fisher Street SE,
Calgary, AB, T2H 2H8
Email: info@pathwayspediatrics.ca
Phone: 403-455-4072

Okanagan
#110, 3121 Hill Road
Lake Country, BC. V4V 1G1
Email: info@pathwayspediatrics.ca
Phone: 250-215-4417

Family Services for Children with Disabilities (FSCD)

First Nations Health Consortium & Jordan’s Principle

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