2023 Summer Programs

2023 Summer Programs

Registration Form
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
School Name*
Grade*
Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Work Number*
Email*
Occupation/Employer
Emergency Contact Information-Alternate Pick-Release
Emergency Contact #1
Name*

First NameLast Name
Mobile Phone Number (Primary)*
Work Phone
Email*
example@example.com
Relation to child*
Emergency Contact #2
Name*

First NameLast Name
Mobile Phone Number (must be different than primary number above)*
Work Phone
Email*
example@example.com
Relation to child*
Please list those people who are permitted to pick up your child*
Your child will not be released to anyone that is not listed above. Please contact us in advance for occasions where an individual not listed will be picking up your child.
Medical Release Information
Insurance information
Name of Health Insurance*
Policy Number*
Primary Physician*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Hospital Preference*
Please list any medical conditions, including any that require maintenance medication (i.e. Diabetes, Asthma, Seizures). If medication needs to be administered while your child is at camp, you will need to come to camp to administer medication. No staff is allowed to administer medication. *
Is your child presently being treated for an injury or illness, or taking any form of medication for any reason? If your answer is yes, please explain:*
Is your child allergic to any type of food or medication?*
If yes, please explain:
Does your child require one on one assistance at their school, ABA center or daycare?*
If answered YES, please explain:*
Does your child have a diagnosis that will assist with program planning? If so, please explain:*
Does your child require special accommodations? *
If yes, please explain. Also, please provide us with helpful information if your child becomes upset, such as calm down strategies used at home or school. Please put n/a if they do not require special accommodations.*
Is your child potty trained?*
If no, please explain current training status:
Does your child require a special diet?*
If yes, please explain:
The purpose of the above listed information is to ensure that medical personnel have details of any medical condition which may intefere with or alter treatment.
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.
Parent's /Guardian Initials*
How you heard about Therapeutic Learning Center Summer Programs?*

WebsiteFlyerWord of mouthSchoolFacebook/InstagramOther
Terms of Agreement

The Therapeutic Learning Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded unless a child is unable to participate due to an accident or illness per physician orders.
I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and or webspace:*
Waiver

THERAPEUTIC LEARNING CENTER, LLC

PARENT

Permission Slip, Waiver of Liability, Indemnification, Medical Agreement

and Grant of Rights

Permission Slip

I, the parent/legal guardian of this participant, hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Summer Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this Program.

Waiver of Liability

My signature below indicates my understanding of the details of the Program. On behalf of my child, I voluntarily agree to accept any and all risks associated with their participation in the Program. On behalf of my child, I agree to forever indemnify, hold harmless, waive, and release TLC, its respective officers, members, employees, insurers, and representatives (“TLC Group”) thereof, from liability for any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have on my behalf or on behalf of my child, known or unknown, directly or indirectly, for any losses, damages, or injuries, including death, arising from, but not limited to, negligence, omissions, or fault, by or on behalf of TLC.

Indemnification

I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the Program.

Medical Agreement

If the participant has any special medical problems, allergies, dietary needs, handicap, special prescriptions, etc., please list (and use additional sheets if necessary) I have explained them in the registration form above.

In case of an emergency, all attempts to reach me should be made to the telephone number(s) stated above on the registration form.

If any emergency medical procedures or treatments are required during the Program, I hereby consent to the staff of TLC’s Program, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter. My signature below also indicates that my child is in adequate physical condition to participate in the Program.

GRANT OF RIGHTS

I, Parent/Legal Guardian, grant TLC the right and license to use my child’s liken, photographs and other attributes (collectively, “Approved Attributes”) to promote and advertise TLC’s services in the media including TV, radio, print advertising, point-of-sale materials, promotional materials, grass roots marketing efforts, public relations efforts and the Internet (to include but not be limited to web banners, blogs and social networking sites).

Declaration

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, WAIVER OF LIABILITY, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

Severability

The Undersigned expressly agrees that the foregoing Release, Waiver and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.

READ BEFORE SIGNING
Initials*
BEHAVIOR

We understand that children with behavioral challenges benefit from a therapeutic environment. However, if your child has aggressive tendencies or demonstrates 3 or more aggressive behaviors towards other children or staff members, they will be asked to return home without a refund. In this case, one on one therapy services may be a better fit for your child.
Please acknowledge an understanding our behavior policy.

Clear
THERAPEUTIC LEARNING CENTER, LLC

Therapeutic Learning Center Programs Policies

Welcome to Therapeutic Learning Center’s Intensive Clinics! We are looking forward to a developmentally supportive, enriching and fun experience with your children. It is our philosophy at Therapeutic Learning Center that childhood should be a time full of fun, warmth, security, sharing, exploring, and discovery. Our goal is to provide a therapeutic atmosphere that encourages social, emotional, physical, and intellectual growth and development of the child.

WHAT TO EXPECT:

The children will be split into groups of 5 or less based on age and function, led by a therapy tech and supervised by one of our occupational or speech therapists.
Your child will participate in several therapy based groups challenging fine motor, gross motor, and social skills with different activities and games.
Feedback will occur verbally at the end of each day and electronically on Brightwheel.

ON THE FIRST DAY, PLEASE BRING AND LABEL EACH ITEM:

A backpack or bag with your child’s name
One complete change of clothes (shirt, shorts, socks, underwear) in a Ziploc bag Water bottle of your choice with name on it.
Any diapering supplies including diapers and wipes.
Daily lunch with a meal that does not require heating or extensive preparation.
A snack if your child is on a special diet (otherwise we provide a snack).
A labeled nap mat and blanket.

BEHAVIOR

We understand that children with behavioral challenges benefit from a therapeutic environment. However, if your child has aggressive tendencies or demonstrates 3 or more aggressive behaviors towards other children or staff members, they will be asked to return home without a refund. In this case, one on one therapy services may be a better fit for your child.

CARPOOL INSTRUCTIONS

Arrival will be between 8:50 am and 9 am, and then pick up between 2:45 and 2:55 pm. Our Intensive Clinics are located at our Metairie Clinic at 3329 Metairie Road.

For arrival, please go to the long parking lot between the buildings entering on Metairie Road and exiting on Athania Pkwy. Our therapist and therapy techs will be outside ready to greet you and your child for the day!

For pick up, please arrive in the back parking lot between our therapy buildings where drop off occurred during scheduled pick up times and our staff will greet you and provide feedback for the day. If the staff is not outside yet, please ring the doorbell and they will be with you shortly! Please do not enter the building without being accompanied by a staff member, for confidentiality purposes. Please note that you must pick up your child no later than 2:55 pm as we have afternoon outpatient clients beginning promptly at 3pm.

ILLNESS

For the well-being of the children, please do not send your child when sick. NO CHILD WHO ARRIVES AT TLC, NOTICEABLY ILL, WITH A RASH, PINK EYE, EXCESSIVE COUGH, VOMITING, DIARRHEA, OR FEVER WILL BE ALLOWED TO ATTEND. Should your child becomes ill during the day, a parent or guardian will be notified immediately and asked to pick up your child. If your child becomes sick at home and is not able to attend Building Blocks, please email programs@tlcnola.com or call our office at 504-565-7300 as soon as possible.

DRESS CODE (PLEASE LABEL ALL CLOTHES WITH FULL NAME)

Children are encouraged to wear comfortable play clothes and tennis shoes that can get stained. Daily activities include active and messy play, and the children should feel comfortable as they engage in a variety of play and projects. Clothing should allow for ease of potty training when managing their clothes.

TOILETING

If your child is not toilet trained, please provide necessary supplies for the day time, including diapers, wipes, and a change of clothes. If you are using a reward system such as a snack or toy or reward chart, please send that as well so we can implement the program while they are at the center.

SNACK/LUNCH & ALLERGIES

A snack and water will be provided mid-morning and mid-afternoon. If your child has any dietary restrictions, food allergy, or special eating instructions, please inform the sta. A “Snack Challenge” will occur twice per week in an eort to provide the children with opportunities to try new foods. A variety of fruits and vegetables will be offered.

Please send a daily lunch with minimal to no food preparation needed (no heating). Please mark their lunchbox and water bottle with their first and last name. Please send any utensils required in their lunchbox. For the safety of all, we have a Nut-Free Classroom Policy. Please do not send your child with any items containing nuts or nut related ingredients of any kind. Thank you for your understanding and cooperation with this policy.

EMERGENCIES

In the event of a personal emergency, please call the office (504-565-7300) to notify us of alternate arrangements for the pick up of your child.

If there is a weather event that requires your child to be picked up, we will contact you and request that you pick up your child immediately or make arrangements for a designated person to pick up your child. No refunds will be given for weather event-related closures.

Please notify TLC through email at programs@tlcnola.com or phone 504-565-7300 if:

Someone other than the usual person will be picking up your child. Your child will be released ONLY to persons you have designated on your information form under the pick-up list and will be asked to show an ID if we are not familiar with them.

ABSENCES/VACATION/WEATHER

Refunds or prorating will not be issued for unexpected absences, expected absences, early pick up, late arrival or inclement weather. This includes but not limited to sick days, vacation days, or leaving early/arriving late due to personal commitments or prior appointments.

If you have any questions or need us for any reason, please call the front office at 504-565-7300 or email programs@tlcnola.com.

We are looking forward to a fun adventure with your children!

Our best,

Jenny & the TLC Staff

PLEASE READ AND ACKNOWLEDGE YOUR UNDERSTANDING OF OUR POLICIES AND EXPECTATIONS:
Parent/Guardian Signature*

Clear
Printed Name of Parent/Guardian*
Date*

MonthDayYear
Date
2023 Summer Programs

Due to our programs filling up very quickly, all children will enter under the status "waitlisted" until our Program Director contacts you to confirm the weeks enrolled. You will also be contacted if the program is full and your child is placed on the waitlist.
Weeks with asterisk are 4 day weeks and priced differently than 5 day weeks. Prices are as follows: Half days (9 am-12 pm)- 290/week; Full days (9 am-3 pm) - 450/week; 4 day weeks half days - 232/week; full days 360/week. Please select the weeks you wish to enroll your child below:*

Week 1*- Full DaysWeek 1*- Half DaysWeek 2- Full DaysWeek 2- Half DaysWeek 3 - Full DaysWeek 3- Half DaysWeek 4 - Full DaysWeek 4 - Half DaysWeek 5- Full DaysWeek 5- Half DaysWeek 6*- Full DaysWeek 6*- Half DaysWeek 7 - Full DaysWeek 7 - Half DaysWeek 8 - Full DaysWeek 8 - Half DaysWeek 9- Full DaysWeek 9- Half Days
Locations able to attend:*

Metairie - 3329 Metairie RoadElmwood - 524 Elmwood Park Blvd Suite 120
Please select from the following payment options:*

Pay full balance in one transactionPay in 2 installments
PLEASE INITIAL BELOW: If paying all at once, payment is due by March 15th. If paying in 2 installments, 50% of the payment is due March 15th and 50% is due by April 15th. If revoking enrollment before April 15th, 50% of the total invoice will be refunded. Please look for an invite and invoice from Brightwheel and email programs@tlcnola.com with any questions. Thank you and we look forward to working with your children!*
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