Parent/Guardian Full Name: *

Child's Full Name: *

Child's Date of Birth: *

Parent/Guardian Email Address: *

Parent/Guardian Phone Number: *

Does your child require 1:1 support or accommodations?: *
YesNo

If yes, 1:1 Support Disclaimer:
Our Sensory & Social Play Class is designed as a small-group experience for children ages 4–8 years. At this time, we are unable to provide dedicated 1:1 support during these sessions.

Does your child have a diagnosed disability, developmental delay, or other special need?: *
YesNo

If yes, please specify your child's diagnosis or diagnoses:

How does your child typically participate in group settings?: *
Participates independentlyParticipates with occasional supportRequires frequent adult supportHas difficulty participating in group activities

How does your child typically communicate? (Verbal, uses short phrases, full sentences, gestures, AAC device, etc.) *

How well is your child able to follow simple one- and two-step directions in a group setting? *
ConsistentlyWith occasional remindersRequires frequent one-on-one support

Does your child have any behaviors that could affect their own safety or the safety of others during a group activity? *
NoYes (Please describe)

How does your child respond to sensory input such as music, loud noises, movement, or busy environments? *
Enjoys sensory activitiesTolerates them wellMay become overwhelmedPlease describe any sensory sensitivities or supports that help.

Are there any accommodations or support strategies that help your child participate successfully in group activities? *
NoYes (Please describe.)

Please share anything that would help us best support your child during the class:

Is your child currently enrolled in school?: *
Yes – PreschoolYes – Elementary SchoolHomeschooledNot currently enrolled

Emergency Contact Name: *

Emergency Contact Phone Number: *

Any allergies, medical information, or other important considerations we should be aware of (optional):

Class Disclaimer:

To provide a safe and positive experience for all participants, this class is designed for children who can participate in a small group setting. If your child requires continuous one-on-one assistance or has behavioral needs that may impact their safety or the safety of others, this class may not be the best fit at this time. We look forward to offering future programs specifically designed to support children who benefit from individualized accommodations.

By submitting this waiver, you acknowledge that all information provided is accurate and complete to the best of your knowledge.*

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