I, the responsible party, give permission for my child listed above, to participate in a developmental screening by Moving Mountains Therapy Center, PLLC. I agree to share the results of this screening with the site administrator and staff, if applicable.
Waiver of Liability: I hereby release Moving Mountains Therapy Center’s, P-LLC, Eat.Move.Grow, S-Corp’s, and Stack Speech Therapy Group, S-Corp’s principal owners, therapists, employees and representatives and all other individuals or organizations acting on behalf of Moving Mountains Therapy Center, Eat.Move.Grow., and Stack Speech Therapy Group from any and all claims which I or my organization may have, resulting from or in connection with my child's participation in Moving Mountains Therapy Center’s, Eat.Move.Grow.’s, and Stack Speech Therapy Group’s programs. This includes, but without limitation, any claim, demands or causes of action for injuries to the children we serve, including but not limited to injuries resulting from the use of any play/therapy equipment during the program. I understand that our staff should be present at all times during the delivery of service. If our organization chooses not to, I understand that the aforementioned statements still apply in my staff’s presence or absence during the services provided. This agreement is signed for the purpose of fully and completely releasing, discharging, and indemnifying the Moving Mountains Therapy Center, Eat.Move.Grow., and Stack Speech Therapy Group in connection with their programs from all liability as herein described.
Disclaimer: This screening does NOT replace a formal evaluation from a licensed speech-language pathologist, or physical or occupational therapist, or a mental health counselor diagnose a delay or disorder or qualify your child for therapeutic services.