March Break Registration Form
Event Timing: March 11-15 2019, 8 am till 4 pm
John@spectruminsights.ca
613.220.5920
http://www.spectruminsights.ca

All potential applicants must have been previously interviewed or already attended a Spectrum Insights event before registering. *
Required
Students Name: *
Your answer
Please note: Our programs are comprised of and best suited to students "classically" diagnosed with Aspergers or FASD, ADHD, PDD-NOS and a mild learning disability. That being said, we teach Social and Life skills to any student who wants to learn how to be more independent and make new friends. Students should be able to have reciprocal conversations, take direction handle transitions and able to self regulate. After the form is completed we will arrange a time to meet you and your child for a short interview. I like to keep it casual and stick to coffee shops, this way I can observe your child in a public setting, see how he/she interacts at the cash or what help they need. Observe communication w/ mom and dad, reciprocal conversation w/ me, learn their interests and get feed back on goals from parents. No worries if your child needs extra help at the cash, I just want to discern where they are at socially and level of independence. *
March Break Registration - March 11-15, 2019 - PAYMENT SECURES YOUR SPOT. We are limited to 6 students *
You can skip the contact details if there are no current changes. If this is your first time attending, please fill out the following questions.
Your answer
Parents Name(s)
Your answer
Date Of Birth
Your answer
Medical Concerns / Conditions
Your answer
In case of emergency info - Please include your phone number along w/ I.C.E contacts. *
Your answer
Individuals Authorized to Pick up / Drop Off
Your answer
Photo Permission - Any photos/videos taken may be used to help promote and document the activities of Spectrum Insights events through our website, Facebook, Twitter and Instagram. Names and personal information of the students WILL NOT be used. *
Required
Waiver: It is my understanding that an activity of this nature has inherent risks involved. All reasonable precautions for the safety and health of the participant will be taken. He/she will be properly supervised in activities. In the event of accident or sickness, Spectrum Insights, sunnyside Weslyan Church, its staff and volunteers are released from any liability. In the event of injury requiring medical attention, I authorize treatment for the participant and understand that reasonable attempts will be made to contact me, should such a situation occur. Please note this group is not appropriate for any aggressive behaviours or students that may potentially run off. Students must be able to exhibit independence and ability to follow complex group instruction. *
Required
Dietary restrictions
I understand that a non refundable payment of $400+hst guarantees my child a spot at the March break Camp. We will not be reimbursing for missed days. Should there be a error on our part where the camp is cancelled, we will reimburse the cost of the day's/week missed. Please consider the group and your child's interests, we are not able to offer refunds. Students with ASD can be changeable when it comes social groups, if you feel your child cannot commit to our social groups, camps or socials then please reconsider joining as refunds are not given. Drops ins/visits are encouraged in order to determine whether our groups are a good fit for your child. We will do out best to encourage and motivate your child should he/she become anxious about attending. Our groups are meant to be fun, laid back and make social experiences a lot easier. *
Required
Payment is for March 11-15, 2019 *
I will pay Via: *
By typing my name below, I confirm that I have read and understood the Registration Form. I also confirm that the information I have provided on this form is true, correct, and complete. *
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