Manhattan East Associates, Inc.

Pediatric Occupational Therapy

Early Childhood Sensorimotor Class Registration Form

Child’s Name: ______Today’s Date: ______

Child’s Date of Birth: ______Age: ______Sex: (Male or female) ______

Address: ______Apt. #: ______

City: ______State: ______Zip: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Emergency Contact Name: ______Phone: ______

Physician’s Name: ______Phone: ______

Known Allergies: ______Physical Limitations: ______

Mother’s Name: ______Email: ______

Home Phone: ______Work Phone: ______Cell Phone:______

Father’s Name: ______Email: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Caregiver’s Name (if bringing child to class): ______Cell Phone: ______

School your child attends (if applicable): ______Grade: ______

Child diagnoses, if any: ______

Does your child receive services? Please list and provide frequency and duration and name of service providers. ______

______

______

Please provide any further information concerning strengths and weaknesses your child may exhibit as it may pertain to group interaction skills such as eye contact, attention span, verbal abilities etc.

______

Class /Program Information:

Please check the class you wish to attend:

Ö / Class Name / Day / Time / Fee
Early Childhood Sensorimotor Class / Tuesdays / 10:00-10:45 / $500.00 for 6 sessions (11/10,11/17,11/24, 12/1, 12/8, 12/15)
Early Childhood Sensorimotor Class / Thursdays / 10:00-10:45 / $500.00 for 6 sessions
(11/5, 11/12, 11/19,12/3, 12/10, 12/17)

Payment Information:

We accept payment in the form of cash or check.

Please make checks payable to:

Manhattan East Associates, Inc.

1675 York Ave, Suite 1A

New York, NY 10128

For Office Use Only

Date received______Received By ______Date Processed ______

Cash______Check______Check Number______Total Amount Paid $______

Cancellations, Refunds and Make-Ups:

1.  Manhattan East Associates, Inc. reserves the right, prior to the first class or after, to cancel a course due to insufficient registration, with full refund.

2.  Manhattan East Associates, Inc. is responsible for a make-up class only if a cancellation is due to the absence of the instructor or the closing of the facility.

Medical Release:

I understand and fully recognize that my child’s participation in any activity carries with it a risk of physical injury. I, on behalf of myself and my child, agree that Manhattan East Associates, Inc. their employees, and/or volunteers shall not be liable to me or my child or legal representatives for the injury or damage, however caused, resulting directly or indirectly from my child’s participation in any Manhattan East Associates, Inc. program, at any time preceding, during or after such program is in session, and I hereby waive, and release and discharge Manhattan East Associates, Inc. their employees, and/or volunteers from, any and all actions, claims and demands which I or my child may have in connection with any such injury or damage.

Parent’s Signature: ______Date: ______

Please submit completed forms and payment to Manhattan East Associates, Inc.

1675 York Ave. Suite 1A

New York, NY 10128

Phone (212) 410-4000

Fax (212) 410-7156