Personal Coaching - Registration Form
Our programs & Coaching are best suited to students diagnosed as level 1 Autism (Aspergers). We do have students with: FASD, ADHD, PDD-NOS and mild learning disabilities. Students should be able to have reciprocal conversations, take direction, handle transitions and sensory stimuli (oc transpo, busy streets, malls, movie theaters, walking, hot summer days) and able to self regulate.
Students Name: *
Your answer
Parents Name if student is under 18
Your answer
Date Of Birth *
Your answer
Medical Concerns / Conditions
Your answer
Your contact info: Please include email and phone number. *
Your answer
Emergency Contact info - please include telephone numbers and contact names *
Your answer
Individuals Authorized to Pick up and Drop Off. Is the student able to arrive/depart on their own? *
Your answer
I understand that the coaching sessions are $40/hr+HST = $45.20 *
Required
Cancellation Policy - A full 24 hours notice is required for cancelling appointments. If you cancel with less than 24 hours before your appointment time, you will be billed for 50% of the cost of your appointment, that is, $20.00 for a 60 minute appointment. If you cancel with less than 12 hours before your appointment time, you will be billed for 75% of the cost of your appointment, that is, $30.00 for a 60 minute appointment. Clients who fail to show up for a scheduled appointment (“no show”) are billed a flat rate of $45.20. *
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
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
Dietary restrictions *
Sessions are billed weekly , payment options below: How will you be paying? *
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