Group 1: 8-12 years of age will meet from 3:30 pm - 4:30 pm
Group 2: 13-16 years of age will meet from 5:00 pm – 6:00 pm
Event Address: Virtually!
Contact us at 906-273-1121 or
Attendees Name (First, Last)
Parent or Guardian Name (First, Last)
Address, City, State, Zip
The following information helps us plan appropriate educational components for Sibshop sessions.
Name of sibling(s) with special needs. Please include age and nature of disabilities.
What are your goals in enrolling your child in the Sibshops Program?
Do you have any particular topics that you would like to see addressed during the Sibshops?
Is your son/daughter on any medications, or have any health concerns that we should know about?
Please provide any other information that you feel would make this an enjoyable and educational.
*Scholarships may be available. Contact Carrissa Rondeau, at C.Rondeau@fbsmi.com for more information. * Please read consent below by submitting this form you provide consent for these services through Functional Behavior Services.
In order for Functional Behavior Services’ (FBS) social groups to work effectively, a supportive
atmosphere will be created and maintained by the facilitators and expectations must be understood by
the participants. To ensure a safe and supportive environment, it is essential that all participants read
and understand the following (will also be reviewed during the first group session with participants).
Group sessions are meant to be a safe place for participants to share experiences and thoughts with
peers. For this reason, what peers say in the group, will remain in the group. Members are expected to
keep anything said by other members during group confidential. Confidentiality depends on you and
fellow group members following these guidelines:
When talking to people outside of the group, you cannot discuss any information that may help
identify another member in the group. This includes, but is not limited to, names of group
members, physical descriptions, or specific interactions with other group members.
You are allowed to tell others that you are a group member or participating in the group. You
may share information about yourself in respect to your group experience, your personal
reactions, feedback you have received, changes you have made, or skills you have learned.
To ensure everyone’s privacy, FBS cannot give you other member’s personal information (e.g.
address, phone number, etc.). If you would like to exchange this information with another group
member, please do so with your own discretion.
If you breach confidentiality, you may be asked to leave the group.
Environment/Area for Group Participation:
To ensure confidentiality and active participation, you will need a quiet, distraction free, area to
participate in the virtual social group. This will guarantee that interruptions and disturbances are
minimized. A quiet environment will also promote group confidentiality.
Due to the nature of the virtual group, it is imperative that participants have a basic
understanding on how to navigate the technology on their own so as to limit interference from
others not intended to participate in the virtual group.
Release of Injury
I, as the parent/guardian assume all risks and hazards of the conduct of this program and release from
responsibility any person providing transportation to and from activities. In case of injury, I do herby
waive all claims or legal actions, financial, or otherwise against Functional Behavior Services, their
elected officials and employees, the organizers, sponsors, supervisors or volunteer connected with the
program. In absence of a signature, payment of fees and participation in the program shall constitute
acceptance of the conditions set forth in the release.
I grant full permission to use any photographs, video, or any other record of this program for any
purpose. Photos may be used on social media platforms as a way of promoting the Sibshops program at
Functional Behavior Services, and informing the public about this resource.
If you do not understand any part of this agreement, please ask any questions prior to signing the
agreement. I understand that checking this box constitutes a legal signature confirming that you have
read the statements above and agree to comply with the policies listed in this document.
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