Foundation LIFE ENRICHMENT subscription form

UNIVERSOUL KIDS LIFE ENRICHMENT PROGRAM

by Solid Ground Foundation for Behavioral Services
UniverSoul Kids Life Enrichment Program by Solid Ground Foundation for Behavioral Services provides behavioral health and support services to youth ages 3y to 14y, including children with disabilities and English learners. Monthly membership-based services are available. Medicaid recipients and/or residents of Robbins Illinois referred through participating agencies are eligible to recieve a service discount. Contact us directly for more information at 708-290-9019.

Program Ends: Thursday, May 25th 2023

Location: 13136 S Western Ave, Blue Island, Illinois

Early Learner Enrichment Time (3y-4y): Thur. 9a-11a OR 12p-2p

After School Enrichment Time (5y-14y): Tue., Wed., Thur 3p-6p
Member Information

Please submit one form per member
Learner Name*

First NameLast Name
Sex*

MaleFemaleNon-Binary
Current School
Current Grade*
Date of Birth*

MonthDayYear
Age:*
Allergies or Other Medical Conditions:*

PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
Do you have legal custody of the child being registered?*

YesNo
Emergency Contact (other than the parent above)

In the case that we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent above).
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number

Covid-19

Precautions & Procedures
In efforts to maintain the safety of Life Enrichment members and staff follow CDC Guidelines which encourage staff and participating member to
- Wash or Sanitize Hands Frequently
In the event of illness due to Covid-19 we require all members and staff to provide a negative Covid-19 test results and remain "out" symtom-free for 72-hours.

Photographic & Media Consent
You are being asked to give consent for the collection and use of your child’s personal images by photography or video recording. If you give consent, you are acknowledging that these images may be used on the Solid Ground Foundation for Behavioral Services website, newsletters, and publications as well as distributed to members or used for promotion in the future. No personal information, such as names, will be used in any publications unless express consent is given.
Consent*

I HEREBY GIVE consent to the collection and use of my child’s personal images by photography or video recording.I DO NOT give consent for Solid Ground Foundation for Behavioral Services to collect and use my child’s personal images by photography or video recording.

Parent Involvement
UniverSoul Kids Life Enrichment Program by Solid Ground Foundation for Behavioral Services is family centered and works collaboratively with all "village members" to ensure the needs of our members are met.

In efforts for us to maximize individualized service outcomes for young "souls" we require bi-monthly parent involvment.

By enrolling your child, you HEREBY agree to participate in monthly 1:1 coaching and group guidance sessions when possible.
Consent*

I HEREBY agree to participate in bi-monthly parent involvement sessions or seminars

Consent to Participate
I hereby consent to the participation of my child in all supervised Life Enrichment activities including academics, counseling, indoor, and outdoor recreational games, crafts, snack times, meals, and/OR crisis management.

I, the Parent or Guardian named below, authorize Life Enrichment personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above.

I, the Parent or Guardian named below, undertake and agree to indemnify and hold blameless Solid Ground Foundation for Behavioral Services, its Personnel, its Leaders, and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the Life Enrichment Program, as well as of any medical treatment authorized by the supervising individuals representing Solid Ground.

This consent and authorization is effective when participating in or traveling to Life Enrichment events.

I have read, understood, and agree with above.
Name*
Signature*

UniverSoul Kids Program Menu

Services & Programs

Select Enrollment*

EARLY LEARNER LIFE ENRICHMENT$200.00

Members attend 1x per week on Thursdays 9a-11a OR 12p-2p. Membership fees and payment subscription electronically deducted monthly on the 11th of each month so long as your child is actively enrolled. Email to disenroll. Select day(s) of attendance in STRIPE. ROBBINS RESIDENTS ENTER COUPON CODE

AFTER SCHOOL Life Enrichment (1x per week) $300.00

Members attend 1x per week from 3p-6p on Tuesday, Wednesday, & Thursday. Membership fees and payment subscription electronically deducted monthly on the 11th so long as your child is actively enrolled. Email to disenroll. Select day(s) of attendance in STRIPE. ROBBINS RESIDENTS ENTER COUPON CODE

AFTER SCHOOL Life Enrichment (2x per week)$400.00

Members attend up to 2x's per week from 3p-6p on Tuesday, Wednesday, & Thursday. Membership fees and payment subscription electronically deducted monthly on the 11th so long as your child is actively enrolled. Email to disenroll. Select day(s) of attendance in STRIPE. ROBBINS RESIDENTS ENTER COUPON CODE.

AFTER SCHOOL Life Enrichment (3x per week)$500.00

Members attend up to 3x's per week from 3p-6p on Tuesday, Wednesday, & Thursday. Membership fees and payment subscription electronically deducted monthly on the 11th so long as your child is actively enrolled. Email to disenroll. Select day(s) of attendance in STRIPE. ROBBINS RESIDENTS ENTER COUPON CODE.

Enter coupon

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

UNIVERSOUL KIDS LIFE ENRICHMENT PROGRAM

Member Information

PARENT/GUARDIAN INFORMATION

Emergency Contact (other than the parent above)

Covid-19

Photographic & Media Consent

Parent Involvement

Consent to Participate

UniverSoul Kids Program Menu