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New Buds Group Registration
Step
1
of
10
- Participant Information
10%
Child's Name
(Required)
First
Middle
Last
Nickname
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
4
5
6
Gender
(Required)
Male
Female
Non-binary
Parent/Guardian's Name
(Required)
First
Last
Email
(Required)
Relationship to child:
(Required)
Mother
Father
Guardian
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
(Required)
Home Phone
Preferred method of contact:
(Required)
Email
Cell Phone
Home Phone
No Preference
Would you like to add an additional parent/guardian?
(Required)
No
Yes
Second Parent/Guardian's Name
First
Last
Second Parent/Guardian's Email
Second Parent/Guardian's Relationship to child:
Mother
Father
Guardian
Second Parent/Guardian's Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Second Parent/Guardian's Cell Phone
Second Parent/Guardian's Home Phone
Second Parent/Guardian's Preferred Method of Contact:
Email
Cell Phone
Home Phone
No Preference
How did you hear about us?
(Required)
Email
Newsletter
Outside Referral
Regional Center
LA Parent
Social Media
School
Online Posting
Advertisement
Webinar
Other
Please Specify Referral
(Required)
Please Specify Other
(Required)
Emergency Contact #1
(Required)
First
Last
Emergency Contact #1 Phone
(Required)
Would you like to add an additional emergency contact?
(Required)
No
Yes
Emergency Contact #2
First
Last
Emergency Contact #2 Phone
What are your child's main areas of interest and favorite activities?
(Required)
What activities and/or tasks does your child NOT like to engage in?
(Required)
Please list your child's strength and/or special talents (e.g. music, art, building things, etc.)
(Required)
What are your goals for your child while they are involved with this program?
(Required)
Engages in socially inappropriate behaviors (e.g. makes inappropriate comments, inappropriate touching of self or others, impulsive behaviors, etc.)
(Required)
Yes
No
If YES, please explain
(Required)
Does your child have sensory sensitivities (e.g. uncomfortable with certain textures, bothered by loud noises, etc.)?
(Required)
Yes
No
If YES, please explain
(Required)
Difficulty staying seated during group instructional time
(Required)
Yes
No
If YES, please explain
(Required)
Cannot focus on an activity, easily distracted
(Required)
Yes
No
If YES, please explain
(Required)
Difficulty with change in routine/schedule
(Required)
Yes
No
If YES, please explain
(Required)
Difficulty transitioning off of a preferred activity
(Required)
Yes
No
If YES, please explain
(Required)
Can appear defiant
(Required)
Yes
No
If YES, please explain
(Required)
Does your child have a history of seizures?
(Required)
Yes
No
If YES, please explain
(Required)
Does your child have any allergies?
(Required)
Yes
No
If YES, please explain
(Required)
Does your child take medication?
(Required)
Yes
No
If YES, please provide name and dosage of medication
(Required)
Would these medication(s) need to be distributed during program hours?
(Required)
Yes
No
If YES, please provide when it needs to be distributed
(Required)
Does your child have any medical conditions that may impact their ability to participate in our programs?
(Required)
Yes
No
If YES, please explain
(Required)
If you have any other information that you would like us to know, please feel free to add your comments here
Agency Policy Regarding The Reporting Of Child Abuse
(Required)
California law requires that all professionals who work with, care for, or otherwise come in contact with children, must report all known or suspected cases of child/dependent adult abuse and neglect.
Abuse is defined as any instance of physical abuse, physical neglect, sexual abuse, or emotional maltreatment.
If an employee of The Help Group has reason to believe that any kind of child/dependent adult abuse has occurred, a report will be made to the appropriate authority and parent/guardian will be notified.
Please check below that you have read and understand the policy regarding the reporting of child abuse.
I have read and understand the policy regarding the reporting of child abuse
Signature
(Required)
Agency Policy Regarding The Reporting Of Child Abuse
Agency Policy Regarding The Hands On Management Of Behavior
(Required)
Only staff persons certified in CPI may use hands on management as a behavior intervention procedure and ONLY as an intervention in the following circumstances:
a. The child is assessed to be in danger of harming him or herself; and/ or
b. The child is assessed to be in danger of harming others; and/or
c. The child is assessed to be in danger of harming him or herself or others in the process of misusing, abusing or destroying physical property; and/ or
The goal of the intervention procedure is to ensure the safety of the child, his or her peers and the staff. In all cases, the dignity and human rights of the child must be safeguarded. Under no circumstances may any hands on management of behavior be accompanied by any inflictive or retaliatory acts, nor may mechanical restraint of any kind may be used.
All episodes of hands on interventions must be documented and submitted to the appropriate administrator for review and parent notification.
I have read all of these policies and agree to comply with them if your child is accepted into the Kids Like Me program.
Signature
(Required)
Agency Policy Regarding The Hands On Management Of Behavior
Photo/Audio/Name Release
(Required)
By checking the box below, I hereby give consent for my and/or child's image, voice, name and/or family surname to appear in photographs, slides, videotape, DVD, film, audio tape or any other known or future mediums (media materials) or use by The Help Group. I understand that any or all of these media materials may be used by The Help Group, it's corporate entities, and schools for public relations, promotion, advertising, fundraising, training, demonstration, or any other business or educational purpose. I am aware and consent for the media materials to be distributed via any and all channels including the internet.
I give consent
I DO NOT give consent
Signature
(Required)
Photo/Audio/Name Release
Release Agreement
(Required)
Please read this section carefully before signing and be aware that in registering and participating in The Help Group’s Kids Like Me programs, you will be waiving and releasing all claims for injuries or loss or property damage that you (or your child) might sustain. This section must be completed and signed by parent/guardian.
By signing this waiver, you accept responsibility for your child who is willingly participating in a program where there are certain inherent risks and dangers. Please note that all participants have the choice to not participate. You must understand that the risk involved in participation may also include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to accidents which may occur. You understand that, in case of injury, initial treatment may be performed by the staff at The Help Group and in certain circumstances there may be need to obtain emergency transportation and medical care from a medical facility. I understand that any costs incurred for your child for such treatment shall be your sole responsibility.
I agree to waive and relinquish all claims that I (or my child) may have for injuries or damages, as a result of participating in the program or using the facilities or equipment, against The Help Group and their officers, agents, servants, employees and affiliates.
I do herby fully release and discharge The Help Group and their officers, agents, servants, employees and affiliates from any and all claims for injuries, including death, damages, property damage or loss which many have or which may in the future accrue to me (or my child) on account of participation in the program.
This Release Agreement shall remain in full force and effect from the date of execution through the entire term of my child’s enrollment in the group. It may be terminated at any time, by either party, by giving written notice to the other party.
I certify that the named participant below is healthy and capable of participating in all activities without restriction. I understand that it is solely my responsibility to determine whether there is any medical reason that he/she should not participate in an activity.
I agree to the release agreement
Signature
(Required)
I have carefully read this agreement and fully understand its contents I am aware that this is a release of liability and a contract between myself, The Help Group and/or its affiliates, and sign it of my own free will.
Late Fee Policy
(Required)
To maintain the integrity of our Kids Like Me programs, ensure the safety and welfare of each child, and respect the hours of program operation as well as staff schedules, please review and note the following new pick up and late fee policy.
It is imperative that parents or authorized guardians be on time to pick up and sign out children at the designated end time of each registered program. Should parents be late, please know that
fees will be imposed for any and all late pick ups in order to cover additional staffing costs
. There will be no exceptions or warnings. If a parent/guardian is late for whatever reason (flat tire, heavy traffic, weather conditions etc.) a late charge will still be issued. A “no exceptions” policy makes it easier to apply the late policy to everyone consistently and fairly.
The Late Fee Structure Is As Follows:
• 5 to 10 minutes late (past designated end of registered program) = Automatic flat $10.00 late fee
• Every minute thereafter = Adds a $1.00 per minute
• Time is calculated only according to clock in lobby near sign out sheets
• Late fee payments are expected to be paid the same day the late pick up occurred.
LATE PICK-UP PROCEDURE:
If you know you are running late, please contact the program Director and let her know the anticipated time of pick-up. It is helpful for staff to know in advance so they can help your child understand and adjust to the late departure. It also helps the staff plan for appropriate supervision for the child after program hours.
If a parent is late and has not contacted the Kids Like Me Director, the following protocol will occur: First the parent/legal guardian will be called.
If the parent/legal guardian cannot be reached, the child’s authorized emergency contact (s) will be called. We will continue to attempt contact with the parent/legal guardian and/or the authorized emergency contacts until 6:15 pm.
If by 6:15 pm, we have yet to hear back from anyone, we will call the local police department and/or Child Protective Services.
Child Protective Services can be reached at: (800) 552-7096.
Local Police Dept’s: Van Nuys: (818) 374-9500 and Culver City: (310) 837-1221
If you are having consistent difficulties in picking up your child by the time class is scheduled to end please talk to your child’s program Director to help you find resources or assist to find solutions for prompt departure.
Consistent late pick-ups without significant communication may lead to dismissal from the program.
I agree to the late fee policy
Signature
(Required)
I have read and understand the pick up and late fee policy and also understand that my credit card on file will be charged for late fees that may be incurred.
Payment Selection
(Required)
Pay Now
Payment Plan
Payment Plan Code
(Required)
By clicking on the "Apply" button you agree that you will still pay the other half of the amount by the start of the program.
Total
Name
This field is for validation purposes and should be left unchanged.
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