Registration
We look forward to becoming healthy with you!
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Any medical concerns or allergies we need to know?
*
Please Select The Pop Up OT Cross Fit BootCamp Class are you registering for
*
Please Select
November 9th 6:30PM
November 13th 10AM
November 14th 12:30PM
I hereby give my permission for my child to participate in Speech Language Associates's Developmental BootCamp Program at the SLA clinic at 204 Ark Rd #105C, Mt Laurel NJ 08054. I waive and release all rights for any claims against Speech Language Associates LLC for any damages and/or injuries that may occur to my child while participating in SLA Bootcamps. I certify that my child is in good physical health to participate in SLA Bootcamps.
*
yes
I give permission for my child to be included in photos or videos that may be features on the SLA website and/or social media pages. I understand that my child's name will not be linked to the posted pictured or video.
*
yes
no
I understand that if my child is sick, has any COVID symptoms, or is exposed to a family member or friend who is being tested for COVID, my child will not be able to participate. SLA is not liability to any child's sickness but will do its best to maintain cleaning procedures.
yes
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