Group Learning Registration Form

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

      YesNo

      YesNo


      ...

      YesNo

      YesNo

      YesNo


      ...

      Additional Information

      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.
      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).

       

      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!