James Madison University

 James Madison University – Occupational Therapy Clinical Education ServicesMailing Address: 755 Martin Luther King Jr. Way, MSC 9022, Harrisonburg, VA 22801Physical Address: 131 W. Grace St., Rm 1100, Harrisonburg, VA 22807Phone: (540) 568-4980 Fax: (540) 568-26451270115240012701152400Registration & Intake FormProgram Name?: Back to School - tOol TimeCheck the age group for which you are registering: √Age Group*CostDaysWeeks/SessionsStart DateTime**Pre-K*$55 totalMonday-Thursday1 week (4 sessions)08/10/20-08/13/209:15 – 10:00AM**Elementary*$55 totalMonday-Thursday1 week (4 sessions)08/10/20-08/13/2010:15 – 11:00 AM**Middle/High School*$70 totalMonday-Thursday1 week (4 sessions)08/17/20-08/20/2010:00 – 11:00 AM*** Children may be considered for a different age group based on parent preferences, program leader recommendations, and/or program enrollment numbers**Additional supports & activities included in the program: (1) an optional orientation offered the week prior to the start of the programs, (2) specific activities that can be incorporated into the child’s family routines to reinforce concepts introduced during live meetings, (3) open “workshops” led by program leaders at designated afternoon times every camp day.Date form completed:____________________________ Completed by: _________________________________________________Child's Name________________________________________________________________________________ ? Female ? Male FirstLast NicknameChild's Date of Birth _____________________Child’s School System _____________________________________________Please list interests of your child _________________________________________________________________________________What do you hope your child gains from being in this group? __________________________________________________________ ____________________________________________________________________________________________________________-10159976200-10159976200Parent/Guardian Name(s)/Relationship ______________________________________________________________________Primary Home Address ___________________________________________________________________________________ Street CityState ZipHome Phone ( ) Cell Phone ( ) E-mail . .-63499-12699-63499-12699Consent and Agreement: Registration:Following submission of this registration/intake form, a spot will be reserved for your child to participate in the program specified above considering the following enrollment guidelines. Enrollment will be granted:on a first come, first served basis as space allowsbased on fit (appropriateness) between child and program to be determined by the program leader. Payment Terms:Payment should not be made until notification from OTCES confirming your child’s enrollment in the program is received. Instructions for payment will be included in the confirmation notification.Payment must be received by the Friday prior to the first session in order to be registered for the programAugust 7th for group held August 10-13thAugust 14th for group held August 17-20th10% discount for siblings (applies across age groups)Cancellation and refund policies:The program may be cancelled by OTCES prior to the start date due to low enrollment, staffing changes, or other unforeseen circumstances. Notification of cancellation will be provided promptly.The program leader may discontinue a child’s participation if it is determined that the program is not a good fit for your child and all reasonable accommodations and modifications have been made. If it is determined by OTCES that your child’s participation in the program must be discontinued the refund policies below will apply. Refunds can only be made to those who pay via credit card. If payment is made by check or cash, a credit for future services/programs may be offered.No refunds will be made after the end of the 1st day of the group.Program SpecificationsThese programs are community-based programs. They are NOT recognized as therapy services and should not be substituted for therapy services, even if led by a licensed therapist.Photographs and Videos These may be taken for the sole purpose of sharing information about OTCES services or as an educational tool. Please mark this box if you DO NOT give permission for pictures or video of your child to be used as stated above. By signing below, you are indicating that you have read and understand the statements above:_____________________________________________________________________________________________Signature (responsible party)DatePlease submit this form by: Fax or email (preferred)OR mail (will delay processing): 540.568.2645 (fax)JMU-OTCES otces@jmu.edu755 Martin Luther King Jr Way, MSC 9022Harrisonburg, VA 22807Child’s NameAdditional InformationWhat is most important to you that your child gets out of participating in this program?What are your child’s strengths?What are some of your child’s favorite things?What is difficult for your child?Is there any additional information you think would be helpful to best meet the needs of your child?How did you find out about the OTCES group program? Would you like to be added to our e-mail list to receive information on future programs/events? ? Yes ? No ? N/A ................
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