Exershine Registration

Sign Me Up!

Parent's Full Name

Child's Full Name

Child's Birthday

Month

Day

Year

Phone *

Please tell us about your child's strengths.

What is the primary reason for enrolling your child in Exershine.

Please tell us anything that you feel we should know about your child to better support them in this program?

What do you hope is the outcome of this program with your child?

Supports Needed

My child is non-verbal

My child will need 1 on 1 support

My child can participate well in a group setting without 1 on 1 support

Physical Abilities

My child walks independently

My child requires an assistive device (cane, wlaker, wheelchair) to move through their environment

Following DIrections

My child follows directions well

My child sometimes follows directions

My child needs frequent reminders to follow directions

I hereby give my permission for my child to participate in a EXERSHINEkids Bootcamp Program run by KIDS IN MOTION staff. I waive and release all rights for any claims against KIDS IN MOTION, including any damages and/orinjuries that may occur to my child while participating in a EXERSHINEkids Bootcamp class.

I certify that my child is in good physical health to participate in a EXERSHINEkids Bootcamp, and I will remain on the premises(or designate another adult to assume responsibility for my child) during the class to support my child as needed.

Please understand that KIDS IN MOTION and EXERSHINEkids is committed to your child’s safety and these precautions are in place to protect all staff, participants and family members.