Just For Girls registration
Event Timing: September 2019 - June 2020 - 2nd Friday of each month.
Please note our Group is now Full for 2019/20. Drop in spots are all that is available. All potential applicants must have been previously interviewed or already attended a S.I event before registering. We are limiting this group to ages 12-17 unless invited for a drop in event.
My child has been interviewed by the director
My Child already attends a Spectrum Insights program or coaching
I would like to be interviewed. Please see the additional comment section at the bottom of this form.
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.
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.
Date Of Birth
Medical Concerns / Conditions - Please update if there have been changes to your child's health
Emergency Contact info - please include your name, email and phone numbers along w/ those who we can contact in case of emergency.
Individuals Authorized to Pick up / Drop Off
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.
Yes I give permission for my child to be photographed
No I do not give permission for my child to be photographed
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.
I Understand and agree
I understand that a non refundable payment of $282.50 (or adjusted fee/Drop in fee) guarantees my child a spot at the social group. We will not be reimbursing for missed days. Should there be a scheduling error on our part where a monthly social is cancelled and not rescheduled later in the month, we will reimburse the cost of the night 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, then please reconsider joining as refunds are not given. Drops ins are encouraged in order to determine whether the group is 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.
I understand and agree
Our Group is now full, drop in availability only ! Payment is $250+hst for Sept 2019 till June 2020. The socials run on the 2nd Friday of each month starting in September 2019 till June 2020. Drop in's are by invitation only. Price will be adjusted if you join us after September 2019.
I am choosing to sign my child up for 10 months - $250+hst = $282.50 or adjusted fee if after Sept 2018
I was invited for a Trial drop in at $25+hst = $28.25
Deadline is over for the $50 off two groups - Thank you to everyone who took advantage of this offer
I will pay Via:
via Cheque to: John Anderson 316 Robillard Pvt Ottawa ON K1T2V8
Electronic Fund Transfer to:
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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