Handwriting Summer Camp 2019
June 10-14, 9am-12
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Date of Birth *
MM
/
DD
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YYYY
Parent #1 Name (first & last) *
Your answer
Parent #2 Name (first & last)
Your answer
Street Address *
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City *
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Zip Code *
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Email *
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Mobile phone *
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2nd phone
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Diagnosis
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List medications/supplements child is currently taking
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Does the child have any allergies? *
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Gardiner/PLSA Identification Number:
Your answer
Releases and Responsibilities
Sense Able Brain Release of Liability *
This is a legally binding Consent Form and Release of Liability made voluntarily by me, the undersigned Releaser, on my own behalf, and on the behalf of my heirs, executors, administrators, legal representatives and assigns to SENSE ABLE BRAIN. By the execution of this waiver of liability form, I acknowledge that the child listed above is/are capable of participating in the activities. I also assume all risks of the student participating in the activities, whether such risks are known or unknown to me at this time. I release and hold harmless this organization, leaders, employees, contractors, volunteers, and any agents from any claim the student or I may have due to the result of any injury or illness incurred during participation in the Sense Able Brain activities. I accept and assume full responsibility for any and all injuries, damages, and losses that may occur to the student from any participation in the activities. In an emergency, I acknowledge that I am solely responsible for all medical and other costs arising out of bodily injury or any loss sustained through participation in this activity. I authorize program/office/facility staff to secure any licensed hospital, physician, and/or medical personnel for any treatment deemed necessary for the participant's immediate care.
Required
Sense Able Brain Photo/Video Release *
I hereby grant Sense Able Brain Therapy & Learning the irrevocable right and permission to use photographs and/or video recordings of my child(ren) on their website and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me. I understand and agree that such photographs and/or video recordings of my child(ren) may be placed on the Internet. I also understand and agree that my child(ren) may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of them. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of Sense Able Brain. I hereby release, acquit and forever discharge Sense Able Brain, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
Required
Financial Responsibility *
Financial responsibility for services obtained at Sense Able Brain rests with you, the parent or guardian of the above named child, regardless of insurance or other treatment coverage plans. We will provide you with an insurance claim bill each month, and it is your responsibility, should you choose to seek reimbursement, to submit this claim to your insurance company or coverage plan. The insurance company or other coverage plan will determine eligibility, necessity, reimbursement rate(s), and approved number of visits. We encourage you to check with your insurance company before treatment begins if you plan to submit claims for reimbursement for extent of coverage in your plan.
Required
Electronic Signature *
By typing your name in this box, you certify that you are authorized to make decisions for the above named child, that you agree to the liability releases as written, and that you agree to assume Financial Responsibility for services provided by Sense Able Brain Therapy and Learning Services.
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