Enrollment Form - bright balloons inc

BBnormal form

Basic Information
Contact Information
Your Child's Health
About Your Child

Child's First Name

Child's Last Name

Child's Nickname

Child's Date of Birth

Child's Age

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Contact Info

Mother's First Name

Mother's Last Name

Mother's Cell Phone

Mother's Home Phone

Mother's Work Phone

Father's First Name

Father's Last Name

Father's Cell Phone

Father's Home Phone

Father's Work Phone

Emergency Contact Person

Contact's phone

Emergency Contact Person

Contact's Phone

Your Child's Health

CHILD'S HEALTH RECORD:

The general state of health:

Does your child have any known allergies?

Are you concerned that your child may be prone to any type of allergies? If yes, describe?

Does your child have any medical conditions which we should be aware of?

Does your child have any problems with any of the following?

Has your child have any problems with any of the following diseases?

Does your child have any speech, hearing, or visual problems?

About Your Child

What is your child's temperament? Are they easy-going, hard to please, demanding, aggressive, etc?

Are there any food restrictions?

What is your child's favourite food?

Can your child be relied upon to indicate bathroom wishes?

What words does your child use for Bowel movements?

What words does your child use for Urination?

What language(s) are spoken at home?

Does your child have any transition objects such as blanket, bottle, toy, etc?

What are your child's favourite activities, toys, books, or games?

Are there any other comments or information you would like to let me know about?

Any specific concerns?

Bright Balloons Terms and Condition Agreement

Terms and Condition Agreement

I have read and agree to the following Terms and Conditions.

If you cancel within 24 hours of the session, no refund will be made.
Cancellations must be made before 24 hours of the session.
The session will be rescheduled for the next available time slot (within 15 days) if the child is sick. There will be no refund for the session canceled if parents do not take the slot.
All visits to the school or meetings with other therapists (i.e., SLP or OT) will be charged as same as ABA sessions.
For scheduled classes, payment is due 1 month in advance. Payment should be made on the 1st day of the month (i.e., on the 1st of the month). The upcoming sessions will be canceled if the payment is not received.
It is the parent's responsibility to bring their children to the session on time and to pick them up on time. Late pickups after 5 minutes after the session will be charged at the rate of $5 per 5 minutes.
If you would like to talk to a therapist, you can book an appointment in advance or email your concerns. If parents are talking to a therapist for more than 5 minutes a charge of $5 per 5 minutes will apply.
Personal belongings such as a jacket, backpack, lunch bag, and water bottle should be labeled with the child’s We are not responsible for any lost belongings if they are not labelled.
BCBA Programming fees after assessment will be separately charged.