Group Learning Registration Form

Language and Literacy Camp - July 4-8, 9am-12pmLanguage and Literacy Camp - July 4-8, 1pm-4pmLanguage and Literacy Camp - July 4-8, 9am-4pmApraxia Camp - July 11-15, 9am-12pmApraxia Camp - July 11-15, 1pm-4pmApraxia Camp - July 11-15, 9am-4pmApraxia Camp - July 18-22, 9am-12pmApraxia Camp - July 18-22, 1pm-4pmApraxia Camp - July 18-22, 9am-4pmLanguage and Literacy Camp - July 25-29, 9am-12pmLanguage and Literacy Camp - July 25-29, 1pm-4pmLanguage and Literacy Camp - July 25-29, 9am-4pm2 Year Old Play and Language Group - August 2-5, 9:30am-10:30am2 Year Old Play and Language Group - August 2-5, 11am-12pmApraxia Camp - August 15-19, 9am-12pmApraxia Camp - August 15-19, 1pm-4pmApraxia Camp - August 15-19, 9am-4pmApraxia Camp - August 22-26, 9am-12pmApraxia Camp - August 22-26, 1pm-4pmApraxia Camp - August 22-26, 9am-4pm8-12 year old Language and Literacy Camp - August 22-26, 9am-4pmKindergarten Group - Reading Foundations Level 1 - Wednesdays 12:00 PM - 1:00 PM - January 12 - March 16, 2022Kindergarten Group - Reading Foundations Level 2 - Wednesdays 1:15 PM - 2:15 PM - January 12 - March 16, 2022Grade 1 & 2 Group - Reading Foundations Level 1 - Tuesdays 3:15 PM - 4:15 PM - January 11 - March 15, 2022Grade 1 & 2 Group - Reading Foundations Level 2 - Wednesdays 4:45 PM - 5:45 PM - January 12 - March 16, 20222 year old - Play & Language Group - Thursdays 9:00 AM - 10:00 AM - January 13 - March 17, 20223 & 4 year old - Play & Language Group - Thursdays 10:30 AM - 12:00 PM - January 13 - March 17, 2022

Name of person completing form:

Referred by:

Child's name:

Date of Birth:

Parent/Guardian Name(s):

Phone 1:

Phone 2:

Email:

Full Address:

Emergency Contact:

Emergency Contact Phone:

Alberta Health Care Number:

Doctor's Name:

Doctor's Phone:

Statement of Problem(s)/Concern(s):

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

If yes, please list date and findings:

Has the child been seen by other professionals?: YesNo

If yes, please list date and findings:
...

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

If yes, is your child's aide able to attend camp?: YesNo

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

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

Additional Information

Does your child have any allergies? : YesNo
If yes, please describe:

Additional Information

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

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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. 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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