Social Skills Program

Social Skills Program Registration Form

Name
This field is for validation purposes and should be left unchanged.
Patient Information
Patient Name*
First Middle Last
Patient Date of Birth*
MM slash DD slash YYYY
Age*
Parent/Guardian Name - FATHER
First Last
Parent/Guardian Name - MOTHER
First Last
Primary Care Physician (PCP)*
PCP Phone Number
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number*
Number where you can be reached to schedule an appointment
Cell Phone Number*
Parent/Guardian Email Address*
Chose Clinic Because/Referred to Clinic by*
- Doctor
- Family
- Friend
- Close to Home/Work
- Website
- School
- Other
If "Doctor", enter the doctor's name
If "Other", enter more information
Additional Information
Person Responsible for Bill*
First Last
Billing Phone Number*
Billing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone Number
Permissions and Releases
I recognize as a part of the educational process, there may be times when my child may be video/audio taped for training purposes. Consequently, I grant permission to video/audio tape my child while he/she is in The Social Butterflies Club/ Monarch Club programs. I understand that my child’s name will NOT be used and he/she will NOT be identified in any way during the trainings.*
- yes, I give permission
- No, I do not give permission
I grant permission to use pictures of my child while he/she is in The Social Butterflies Club/Monarch Club programs for advertising purposes and/ or on the company’s website/Facebook page. I understand that my child’s name will NOT be used and he/she will NOT be identified in any way in the advertisements.*
- yes, I give permission
- No, I do not give permission
On occasion, we will be doing some cooking in our groups. However, we need to know if your child has any other allergies. My child*
- does NOT have any known allergies.
- does have allergies
- does NOT have allergies, but I prefer that my child NOT have certain foods
My child has allergies to the following*
I prefer that my child NOT have the following foods*
Child Pickup
The following people (other than parent/guardian) have permission to pick up my child:
Alternative Child Pickup Person #1
First Last
Phone
Alternative Child Pickup Person #2
First Last
Phone
Emergency Contacts
Emergency Contact #1
First Last
Emergency Contact Phone #1
Emergency Contact #2
First Last
Emergency Contact Phone #2
Consent to Treat / Agreement
Please check each of the following. Checking each of the following items and entering your name serves as your electronic signature. With my signature, I agree to the following:
Please check each of the following*
- I allow Social Learning, LLC to provide services to my child.
- I understand that I am fully responsible for any balance and tuition is due prior to group sessions.
- I understand that refunds cannot be issued for any absences from the group.
- I have downloaded, read and understand the fee schedule for services provided by Social Learning, LLC (The Social Butterflies Club/ The Monarch Club Social Skills Program)
- I understand that attendance is essential to meet objectives of the group.
- I understand that I can schedule a make-up for any absences up to 60 days after the missed group.
Please read the following carefully:
- I am the parent or legal guardian of the below named child .
- I certify that my child is physically able to participate in all activities; or may need some accommodations that I am willing to disclose and will be available to assist my child if necessary.
- In the event that I cannot be contacted, I hereby authorize Social Learning LLC (Social Butterflies Club/ Monarch Club programs) and its employees and or representatives and any medical personnel, hospital, and/or physician to give any medical attention to my child.
- I understand that Social Learning LLC (Social Butterflies Club/Monarch Club programs)is not responsible for my child before or after the stated group times. I understand that Social Learning LLC (Social Butterflies Club/ Monarch Club programs)reserves the right to charge a late pickup fee of $5.oo per child for each 15 minute interval or portion thereof, beginning 10 minutes after the stated end time of the program. I agree to pay this fee immediately to the Social Butterflies Club/Monarch club staff should such a charge be required. I understand that my child will not be allowed to return to the program until such fee is paid in full.
- I hereby release and agree to indemnify and hold harmless Social Learning LLC (Social Butterflies Club/Monarch Club programs)its principals, officers, employees, agents, and representatives, from any and all claims of any nature; which I, my heirs, representatives, executors, administrations, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization; for injury or loss that may result from such participation, preparation for such participation, or spectatorship of any and all activities and preparations.
- I agree that Social Learning LLC (Social Butterflies Club/Monarch Club programs) assumes no responsibility for injuries or losses caused by situations or inappropriate behavior beyond its control.
- Social Learning LLC (Social Butterflies Club/Monarch Club programs) will only release children to the parent / guardian or those individuals listed on the registration form as authorized to pick up. A picture ID is required. If a parent is listed as unauthorized to pick up on the registration form, legal documentation must be provided.
With my full knowledge and consent, I expressly give my child permission to attend this program.
By checking the above items and reading the above items, I understand and agree to each item.*
* Enter your name in the field above. This serves as your electronic signature.
Date*
MM slash DD slash YYYY
GROUP Location Preference*
- Town Center Area: 600 Independence Blvd. Virginia Beach, VA 23462
- Great Neck Area: 1157 First Colonial Road Suite 301 Virginia Beach, VA 23454
- Kempsville Area: 5301 Providence Road Suite 90 Virginia Beach VA 23456
- Chesapeake Area: 680B Kingsborough Square Chesapeake, VA 23320
* Please note that group days and times vary from semester to semester. We will do our best to accommodate your preference but it is not guaranteed.
Did you previously pay your $80 screening placement fee while scheduling an appointment?*
- Yes
- No
Placement Fee
Price:
Total
$0.00
Credit Card*
Card Details
Cardholder Name

Social Skills Program Registration Form

Patient Information

Additional Information

Permissions and Releases

Child Pickup

Emergency Contacts

Consent to Treat / Agreement

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