Focus Therapy Services, Inc.
P.O. Box 12192, New Bern, NC 28562 Tel: 672-8676 Fax: 252-672-8677
Specifically
designed for children with Autism Spectrum Disorders
Name
of Student ____________________________________________________
Age____(must
be between 6 and 12 years old) DOB: ____________________
Diagnosis
___________________________________________________________
Other
Medical Considerations_________________________________________
Any
Allergies (“0” if none)__________________________________________
Address
____________________________________________________________
City
________________State__________ Zip ____________________________
Phone
Home _________________Cell_____________________________________
Emergency
contact _____________________phone_________________________
E-mail
address ______________________________________________________
Child’s
personal music interests ____________________________________
Each session
runs in 10-week increments. Sessions
will be from 4:00 PM to 5:00 PM or 5:15 PM to 6:15 PM. Classes will be held in the music room at
Focus Therapy Service, Inc. Class size
is limited to 8. Please register
early.
I give
permission for my child to attend the Music and Movement program. I am aware that there will be a small cost
per 10-week session of $60.00 for each student attending (this equals $6.00 per
class). If the student cannot attend a
particular session, please notify Focus Therapy Services, Inc., 24-hours in
advance. Fees are non-refundable. Donations of funding, music materials or
movement props are gladly accepted.
We encourage
mentors and/or one family member to attend (without charge), if the child needs
hand-over-hand assistance to perform activities.
I hereby release
Focus Therapy Services, Inc., and the Music and Movement facilitators from any
and all liability connected with my child’s participation in this therapeutic
music classes. I acknowledge that my
child is participating in these activities of their own free will and I assume
all risk in connection thereto.
Name of
Parent/Guardian___________________________________
Signature_________________________________________________
Date
____________________________________________________
Checks can be
made payable to Focus Therapy Services, Inc., and mailed to P.O. Box 12192, New
Bern, NC 28561