Child's Name
*
First Name
Last Name
Gender
*
Date of Birth
*
MM
DD
YYYY
Parent / Guardian's Name
*
First Name
Last Name
Email
*
Phone
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please specify any impairment/disability that may relate to your child including any comorbid conditions:
*
Communication Level
Verbal
Verbal echolalia only
Non-verbal
Selective mutism
Medication
Please detail current medication your child is taking and its purpose.
Use of an inhaler for asthma or other respiratory difficulties?
Yes
No
Had a seizure
Yes
No
If yes, approximate date of last seizure
MM
DD
YYYY
If yes, is the seizure controlled with medications?
Yes
No
not applicable
Enjoy playing with other children?
Yes
No
Feel comfortable to work within a fixed space?
Yes
No
Need doorways and other access points closed for safety?
Yes
No
Feel comfortable to be in a room with other children / adults?
Yes
No
If no, is the reason primarily:
(tick all that apply)
Have a history of aggression or antisocial (e.g. spitting) behaviour?
Yes
No
If yes, please describe the behaviour
If yes, what triggers the behaviour?
If yes, when was the last episode?
MM
DD
YYYY
If yes, how frequently has it occurred in the last 2 months?
If yes, how is it best managed?
Any further comments regarding your child's social behaviour?
Are there any specific behaviour management tips that work well with your child?
Yes
No
If yes, please explain:
What words or actions do you use when you see your child doing positive things at home or in school?
Please describe:
List any particular activities that frighten your child (e.g. phobias) or cause him/her to shut down:
Please list your child’s likes areas of interest (these may be used to improve motivation):
Please describe any other information that may be helpful when working with your child:
Waiver and Release Acceptance
*
I hereby agree to the following:
My child has permission to attend a school holiday program (Majestic Wellness Day) at Majestic Movements.
My child is participating in a school holiday program during which she/he will receive information and instruction about therapy activities such as music, exercise, art and yoga. I understand that therapy activities require physical movements as well as an opportunity for relaxation. As is the case with any physical activity, the risk of injury, even serious or disabling is always present and cannot be entirely eliminated. I understand that it is my responsibility to consult with a physician prior to and regarding my child’s participation in any physical fitness program, including music, exercise, art and yoga. I represent and warrant that my child has no medical condition that would prevent her/his participation in physical fitness activities. I declare that the information in this form is accurate and to the best of my knowledge and should my child’s health, wellness, or medical condition change at any time; I will notify the applicable consultant/instructor of these changes immediately.
I hereby understand and acknowledge these risks and unknown dangers and certify that my child has voluntarily decided to participate in an school holiday program which includes physical activity, I agree to the terms and conditions as set out by Majestic Movements.
In consideration of being permitted to participate in therapy activities, I agree to assume full responsibility for any risks, injuries or damages, known and unknown, which my child might incur as a result of participating in the program and/or during, before and after, their time with Majestic Movements. I also agree to assume full responsibility for any injuries or damages, known or unknown that my child may cause at Majestic Movements. I hereby agree to irrevocably release and waive any claims that I have now or may have thereafter against Majestic Movements and all related facilities and premises for any personal injury or negligence to my child. Additionally, the facility, instructor and Majestic Movements are not in any way responsible for any loss or damage to my or my child’s personal property.
If any portion of this release from liability shall be deemed by a Court or competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.
I have carefully read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognise that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law and that it cannot be changed orally.
Media release
*
We would appreciate your support to to allow us to including photos of your child in our promotional activities.
