Client’s Medical Information
Please include your child’s evaluations or assessment as this information is essential for the therapist to be able to provide any services to your child.
THERAPIES – Please indicate which programs you are requesting for your child. Please indicate which day is most convenient for your child to attend. Programs are offered during the day unless indicated otherwise.
Recreational Therapy (Evenings Only):
Social Outing, ages 13 & over:
Respite(Fri-Sun) including overnight:
Summer Camp (Jun 25–Aug 25):
Due to the great demand for services on Saturdays, we may not be able to accommodate everyone’s request. Children who are not in school or attend preschool will be assigned to a weekday session.
PERMISSION FOR PARTICIPATION IN CDH activities - RELEASE OF LIABILITY
I, the undersigned, certify that I am the parent or legal guardian of the above mentioned Participant. I hereby authorize my minor child named above to attend and participate in activities organized by CDH including any of those that are offered off-site for which I have registered my child (herein referred to as “Activities”). I understand that my minor child must obey all established rules and follow the instructions of the person in charge of the Activities. I consent to and understand that the person in charge of the Activities or agents have the right to dismiss my child who is in their opinion a hazard to the safety and well-being of others. I understand that if my child is sent home under such circumstances I will be responsible for all associated costs incurred, including the cost of special travel arrangements. Prior to the participation in any Activity by my minor child, I acknowledge that there are certain risks associated with certain Activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness or even death. Furthermore, In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Accordingly, I acknowledge that participation in such activities involves certain dangers and risks which may expose my child to hazards of bodily injury or property damage, and which may result in my child being unable to contact me or be unable to receive immediate medical care and assistance if injury occurs. By signing this parental consent and liability form, I expressly warrant that my child named above is capable of withstanding both the physical and mental demands associated with any Activity for which s/he is registered. I also expressly assume all risks to my child’s participation in these Activities, whether such risks are known or unknown to me at this time. In recognition of these risks and realities, and in consideration of my child being offered the opportunity to participate in and benefit from the Activities, I agree on behalf of myself and my child to release, waive, and disclaim any and all liabilities of or claims against, CDH , its officers, board members, agents, faculty, employees, and all private persons or organizations volunteering services without charge to transport, supervise, or chaperone my child while participating in such Activities including, but not limited to any or all liabilities or claims for personal injury, property damage, court costs, attorneys’ fees and interest, however, caused or accrued, as a result of my child participating in the Activity.
I hereby authorize CDH and its authorizedrepresentatives and assigns, to photograph, digitally record, videotape, or audio tape, my above named child while s/he is attending or participating in any Activity. I further agree that any or all of the material recorded may be used, in any form, in publications, including electronic publications, or in audio-visual presentations, promotional literature, advertising, or in other similar ways(collectively, “Promotional Purposes”), and that such use shall be without payment of fees, royalties, special credit, or other compensation. I understand that all such recordings,in whatever medium, shall remain the property of CDH
SUBSCRIPTION TO CDH EMAIL NOTICES
CDH will periodically email information pertaining to upcoming events, important dates, and our newsletters; one of the best ways for you to remain informed on important topics related to your child. To opt-in to receive email notices, please check the following box:
MEDICAL AUTHORIZATION / CONSENT FOR MEDICAL TREATMENT OF A MINOR
I recognize that there may be occasions where my minor child named above, may be in need of first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize any CDH staff member, or adult volunteer, in whose care the minor child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the provisions of the Medical Practice Act by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment. As parent or legal guardian of my minor child (Participant named above), I am responsible for the health care decisions of my minor child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement topay for dental, medical, and/or hospital care or treatment to be rendered to my minor child is legally sufficient and that no consent from any other person is required. By signing below I authorize any CDH staff member or adult volunteer, in whose care the minor child has been entrusted to authorize any hospital or physician or other health care provider to bill the following insurance company or companies for the payment of any services rendered to the minor child. I agree to assume responsibility for the charges for such care as rendered to the above named minor child. I authorize any hospital, physician, or other health care provider to release information from the minor child's medical record to the insurance company named below, in connection with thecompletion of any insurance claim form. I have read, understood and agreed to the information above. All releases, authorizations and permission granted above shall remain in effect unless revoked in writing by the undersigned to CDH.
Electronic Signature Agreement.
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/actionto provide CDH information consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.