Mindfulness at the Montessori Registration Form-The Mindful OT 1

Mindfulness at the Montessori Registration Form

Child's First Name

Child's Last Name

Child's Age

Child's Date of Birth

Primary Contact Phone Number

Parent/Caregiver Name

Parent/Caregiver Relationship to Child

Has your child participated in Mindfulness and/or Yoga classes in the past? Please share. :)

Does your child have any restrictions or contra-indications you would like me to be aware of?

Please review the Notice of Privacy Practices and Consent Policies.

NOTICE OF PRIVACY PRACTICES:

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and audits.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Private Practices.

I agree to the terms & conditions of the Privacy Practices.

PAYMENT POLICY ACKNOWLEDGMENT

I understand that this session is private pay only and payment in full is due by the start date of the 22 week session series. I agree to the following session rate.

Session Rate: Please check. (Invoice will be sent to you once Registration Form is completed).

22 week Montessori Mindfulness Sessions: $330 ($15/class)

Other

ILLNESS POLICY:

I understand that my child should be healthy and without symptoms in order to participate in each in-person session. I further understand that following an illness, I will wait 24 hours and my child will be symptom free prior to our scheduled session.

I agree to the terms & conditions of the Illness Policy.

PHOTO RELEASE

I understand that the Mindful OT classes may occasionally take photos or short videos during our sessions for educational and marketing purposes. I understand that no photographs, videos or other images of the sessions will be taken without the consent of the parent/guardian.

Choose 1:

I agree.

I DO NOT agree.

CONSENT FOR PARTICIPATION IN SERVICES WITH THE MINDFUL OT

I am the parent or legal guardian seeking Mindful OT services on behalf of a minor (under 18 years of age). I have the legal authority to agree/disagree to the above consents on behalf of the minor.

I agree to the terms & conditions for participation in services with The Mindful OT.

Signature of Parent or Primary Caregiver

Date

Please share any essential medical history that should be known. Please share developmental milestone highlights that you would like to share.