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Membership Application

Seichou Karate is committed to welcoming and including people of all abilities and experiences at the dojo.  As you become a member of our community, please take a few minutes to tell us about yourself and/or your children.  All information will be kept confidential and used only for the purpose of supporting your learning and development at the dojo.

Every student is an individual and each member of our dojo is important to us.  Our students have many different abilities, strengths, challenges and gifts.  You are welcome to share as much or as little information as you like.  The more information you share with us about yourself, your child and your learning styles, the better able we are to support you in achieving your goals.  This questionnaire is a starting point but please feel free to reach out to us at any time with anything you wish to share or discuss.

Dated: December 10, 2022

First Member's Name

First Name*

Last Name*

Phone*
First Member's Date of Birth*
First Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
First Member's Signature*
Second Member's Name

First Name*

Last Name*
Second Member's Date of Birth*
Second Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Third Member's Name

First Name*

Last Name*
Third Member's Date of Birth*
Third Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Fourth Member's Name

First Name*

Last Name*
Fourth Member's Date of Birth*
Fourth Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Fifth Member's Name

First Name*

Last Name*
Fifth Member's Date of Birth*
Fifth Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Sixth Member's Name

First Name*

Last Name*
Sixth Member's Date of Birth*
Sixth Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Seventh Member's Name

First Name*

Last Name*
Seventh Member's Date of Birth*
Seventh Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Eighth Member's Name

First Name*

Last Name*
Eighth Member's Date of Birth*
Eighth Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Ninth Member's Name

First Name*

Last Name*
Ninth Member's Date of Birth*
Ninth Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Tenth Member's Name

First Name*

Last Name*
Tenth Member's Date of Birth*
Tenth Member's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive Seichou Karate information and news by e-mail.
How did you learn of Seichou Karate®?

How did you learn of Seichou Karate®? *
Emergency Contact

Whom should we contact in the event of emergency?


Name: *

Tel: *

Relationship: *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Nickname:

Which school does your child attend? *
I am interested in the following program(s) for my child:*

1. Why are you/your child interested in learning karate? *

2. What are you hoping to gain from your child (and family) learning karate? *

3. What are you/your child's strengths and challenges? *

4. Does your child have any allergies or intolerances we should be aware of? *

5. Have you/your child experienced bullying? *

6. Do you/your child have any medical conditions of which you want to make us aware? *

7. Do you/your child have any developmental or special needs diagnosis, a working diagnosis or are you exploring whether you might seek a diagnosis, such as: ADHD, autism spectrum disorder, sensory processing disorder, dyspraxia, gross motor challenges, developmental delays, emotional regulation challenges, anxiety, learning disabilities, medical conditions, neurological conditions and physical differences. Please share this with us if you choose to. *

If you have answered yes to question 7, please complete the further questions below:


8. Are you primarily interested in you/your child joining our existing large group classes, smaller dedicated group classes for students with additional needs or you are not sure yet and want to discuss this further?

9. If your child has a diagnosis, is he/he aware of it? Are there any topics that you would prefer not to discuss with your child present?

10. What are you/your child's main day-to-day challenges?

11. What are your main day-to-day challenges in caring for or living with your child?

12. If your child has an Individual Education Plan (IEP) or 504 plan, are there any accommodations or strategies that would be helpful for us to know about? (E.g. my child has preferential seating in school as being closer to the instructor is helpful for processing verbal instructions. Or my child may need a sensory break.)

13. Are there any accommodations or strategies you use at home that would be helpful for us to know about? (E.g. my child has slower auditory processing so we allow more 'think time' after giving an instruction before expecting a response. Or in order to focus my child needs to move his/her body so we limit the amount of time we ask him/her to sit still. Or my child has a hard time dealing with transitions so we give warnings before we switch activities.)

14. Is there anything that you would advise us to avoid doing with or around your child? (E.g. my child is very sensitive to loud noises without a warning)

15. Do you have any further information you wish to share with us? E.g. a copy of your IEP/504, occupational therapy plan or physical therapy plan, recommendations from your pediatrician etc.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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