Infant Toddler Ninja Warrior Registration Form

Every Wednesday in June (3-5 year old group)

______________

Infant Toddler Ninja Warrior is a set of free programs that are offered in our community

*Sessions take place from 9-9:45am at Growing In Motion: 2104 Aspen Dr. Mechanicsburg

June Session Dates:

Wednesday, June 5th

Wednesday, June 12th

Wednesday, June 19th

Wednesday, June 26th

Registration is open to the first 10 children that sign up

Sign up will include every session date above

Your child is not able to attend back to back months to give everyone an opportunity to attend

*Please note that sign up is REQUIRED to attend. We are unable to accept walk-ins.

The 0-3 year old group is for children that are currently receiving early intervention therapy.

Infant Ninja Warrior Registration (3-5) June 2024

Parent/Guardian Name

First

Last

Phone

Child's Name

First

Last

Child's Date of Birth

County of Residence

Who referred you to us?

Date of Autism Diagnosis

I understand that the open gym is not always fully supervised by a therapist. I accept any and all injuries that may occur during this time to myself or my child. I understand that it is my responsibility to watch my child and maintain safety at all times

Yes

I am voluntarily participating in this open gym and in agreement that Growing in Motion is not responsible for any injuries that may occur during the open gym

Yes

I understand that attending the open gym may result in some loss in confidentiality. The open gym is only for Early Intervention families and my attendance will imply my child receives these services. I understand this and willingly accept this.

Yes

I confirm that I will not hold Growing In Motion or Early Bird Therapy liable for any injuries that may occur during this program. I understand that I am solely responsible for the safety of my attending child. Please initial to confirm.

If you are human, leave this field blank.