I. Personal Information
Participant's Name
Parent / Guardian's Name
Address
Phone *
Emergency Contact Information
Additional contact #s such as cell phones can be listed below
II. Background Information
Please provide a brief summary of your child's condition *
Please list any medications your child is taking. Please indicate N/A if no medications are taken. *
Are there any special medical concerns (e.g., seizures, medications, food allergies, other?) (N/A if none) *
Does the participant need assistance with toileting? *
Has your child ever been physically violent (hitting, kicking, scratching, etc.)? *
III. Video and Photography Consent Over the course of the intensive, sessions are often videotaped to monitor a child’s progress and to record motor activities for archival purposes. The footage may also be used for general education and awareness including for conferences, presentations, websites, and social media. Some families will also be asked to participate in a documentary project to record their child’s intensive alongside parent/caregiver interviews. I hereby grant to Spiral Movement Center Toronto the right to use raw footage of the intensive for the purposes above. Parents who agree to these terms will also receive said footage upon request.
I am aware and give consent for Spiral Movement Center Toronto to take photographs and videotape sessions if applicable during the designated time of the program.
IV. Participant Release Form I accept responsibility for my child's own medical coverage. I hereby give permission for staff/ volunteers of Spiral Movement Center, to arrange for any emergency medical care including hospitalization and transportation if necessary, and agree to pay for all expenses and costs incurred thereby. If emergency medical care is required, attempts will be made to contact emergency contact person(s) shown above. I agree to release and indemnify and save harmless Spiral Movement Center, c.o. Andrew Hlavats and their staff from all claims arising from whatever participation in any program organized by the staff or volunteers of Spiral Movement Center by any cause whatsoever. Please note that this form with its legal consents and liabilities remains in effect from the date it is signed and will apply to any future Spiral Movement Center programs that the above-named participant is registered in unless advised otherwise in writing. I, the undersigned, have read and fully understand the "Participant's Release Form".
V. Refunds/Cancellation Policy Due to the logistical requirements necessary for children’s intensives, we require that payment be provided well in advance of your intensive. All intensives are scheduled on a first-come, first-served basis. In the event of a cancellation, we will offer a full refund up to one month prior to the scheduled intensive, and a refund minus deposit up to two weeks prior. We will not be able to provide refunds after this period, except in cases of illness arising during the intensive, in which case a pro-rated cost will be refunded.
VI. Additional Needs/Requirements If you have any additional needs or requirements, please let us know in the field below or by writing us at: info@spiralmovement.ca
Additional Needs/Requirements
Step 2: Payment Please let us know if you would like to make payment in one or two installments. The cost is $2000 AUD. We will send the invoice to you within two days of you submitting your answer. You can pay either the full price upon receiving the invoice, or half now and half in 4 weeks. Please see the FAQ
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Thanks for registering! An invoice will be sent to you within the next two to three days.
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