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Camp Registration – 2 Year Old Play and Language Groups August 2–5
Scott
2023-02-01T16:11:27-07:00
Register
Camp Registration –
2 Year Old Play and Language Groups, July 4 – 7
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Select a camp
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Group 1: 9:30am-10:30am (max 4 kids)
Group 2: 11am-12pm (max 4 kids)
Name of person completing this form
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First
Last
Referred by
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Child's name
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Date of birth
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Parent/Guardian Name(s)
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Primary phone
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Alternate phone
Email
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Full address
*
Alternate contact name
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Alternate contact phone
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Has the child been seen by a Speech-Language Pathologist or Occupational Therapist?
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Yes
No
If yes, please list date and findings
Has the child been seen by other professionals?
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Yes
No
If yes, please list date and findings
My child has an aide at school and/or home?
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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!
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