Please fill out the form below to sign your child up for Creative Approach Development Center's Anime and Gaming social club, Club Tomodachi. Please keep in mind that submission of this form does not verify enrollment in the club and that an intake meeting will be conducted (either in person, virtually, or by phone) to make sure the club is the right fit for your student. If you have any questions, please email info@CreativeApproachOnline.com or call 804-876-2115. Also, be sure to follow Club Tomodachi on Facebook and Instagram to get the latest updates and info about club happenings and events.
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Parent/Caregiver Phone Number
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Emergency Contact Phone Number
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Student's Current Grade
During our meetings, students will have the opportunity to play games, participate in discussions, complete arts and crafts projects, and watch anime. Will your student require any accommodations or resources to participate in the club and complete the activities?
I am not sure
If yes, please describe
What anime does your student enjoy watching?
What do you and your student hope to gain by participating in Club Tomodachi?
Student medical and/or mental health diagnoses
Light snacks will be provided during the meeting. Please list your student's hav allergies or dietary conditions
While this is a group that includes lessons and supports to help with social skill development, it may not be appropriate for those who engage in high levels of challenging behaviors. Does your student engage in any of the following behaviors? (**Check all that apply. Answering yes does not guarantee student will not be able to participate)
Emotional outbursts (crying, screaming, yelling, refusing to participate, disruption of activities, etc.)
Verbal aggression (name calling, making threats, using profanity, etc.)
Physical aggression (hitting, kicking, pinching, biting, throwing objects at others, etc.)
Property destruction (throwing things, knocking things over, punching things, tearing up others items, etc.)
Walking off/Eloping (leaving the room without permission, not returning when called back)
Interrupting others (talking when others are talking, making rude comments when someone says something they do not understand or disagree with)
Refusal to participate (does not participate in group activities and rushes others who do)
The anime episodes that will be selected for viewing will be screened prior to showing it to the group to avoid including those that contain high levels of graphic violence, the use of profanity, and sexual content. While efforts are being made to keep this to a minimum, it must be noted that some episodes will include fighting scenes, and may include the mild use of profanity (1 or 2 words in an episode), or indirectly talk about dating or attraction to the opposite sex. Content that will be shown can best be described as rated G, PG, or PG-13. Please check the box below to acknowledge you have been made aware of this and agree to let your student participate.
I have read this statement and agree
I have read this statement and do not agree and need to further discuss this
Intake Interviews are meetings conducted by Dr. Levi-Shackleford on Mondays and Thursdays between 3:00 pm and 5:30 pm. They typically last about 20-30 minutes and are currently being conducted virtually or by phone. They provide you with the opportunity to learn more about Club Tomodachi and share your student's interests and support needs. Please select a day and time for your intake interview.
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