Consent Authorization Form

Please read carefully.

Your details

Parent or guardian name*

Email*

Child's Full Name*

Child's Date of Birth*

I hereby consent to my child receiving therapy intervention at SPOT as deemed appropriate by the therapist team.*

Yes

I acknowledge and agree to the cancellation policy*

including that I must provide 24 hours notice to the therapist or provide a doctors note if a cancellation needs to be made, otherwise I will be charged in full for the appointment (please find the full cancellation policy on our website).

Yes

I understand that SPOT therapists participate in regular confidential clinical supervision in order to support best practice and continuing professional development. I understand that my child/family case may be presented in supervision within the bounds of confidentially.*

Yes

SPOT Centre Ltd uses suspended equipment for moving, climbing and balancing in order to provide children with beneficial therapeutic experiences. SPOT therapists always exercise the utmost care in order to minimise risk. As with any indoor playground setting, there is always a risk with using playground and gym equipment despite the use of cushions, padding, mats and adult supervision. An important part of risk minimisation is ensuring that you always inform your child’s therapist of any change in health, medication or home situation especially those that may impact reaction time and motor control.

I have fully read the above statements and understand the inherent risks involved during play and activities using the SPOT equipment and give permission for my child to participate. I hereby release SPOT Centre Ltd owners and employees from any liability, claims, demands and causes of action, nor or in the future, resulting from soreness or injury however caused, occurring during or after my child’s reasonable and appropriate participation in therapy.*

Yes

I would like to receive the monthly e-newsletter from SPOT about parent courses, child groups and general SPOT updates.*

Yes
No

I authorise SPOT therapists to photograph/video my child for the sole purpose of keeping clinical records.*

Yes
No

I authorise SPOT therapists to liaise with other professionals who are also involved in my child's therapy and learning. (Please list below)*

Yes
No

Other Therapists

Please note name(s) and contact details of other therapist(s) and educator(s):*

Name	Contact Information

Signature

Signature*

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Phone

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Your details

Other Therapists

Signature

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