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Sessions*

For Sessions Starting May 25th
For Sessions Starting June 1st

Trial Rate this week!*

Wed 1-3pm
Thurs 1-3pm

Choose any individual session or all for a discount.*

Mon 1-3pm
Tues 1-3pm
Wed 1-3pm
Thurs 1-3pm
All Sessions

Total

$0.00

Child's Name*

First Last

Age*

Date Of Birth*

Current Grade (2019 - 2020) :*

School Attended (2019 - 2020) :*

Parents Information

Parents Name:*

First Last

Best Contact Number:*

Best Contact Email:*

Does your child struggle with learning?*

Yes
No

If yes, please explain:

Does your child struggle with attention and focus?*

Yes
No

If yes, please explain:

Regarding current educational expectations, your child is?*

Please explain.

Requirements to participate in video conferencing: We will be using Zoom with a password. You will receive this information via the best contact email provided. Your child will need a good internet connection and a computer or other device that allows video and audio. Your child will be required to keep their camera turned on for the duration of each session. Please be advised that although still a good option, ipads have limited functionality and your child may experience a limited ability to actively participate in some activities.

I have read the above and understand the limitations of a virtual camp. I understand that participation is dependent on my child’s willingness to remain within view of the computer camera. I accept responsibility for ensuring that my child is supervised by an onsite adult at all times while participating in Dynamic Days Virtual Camp. I understand that my payment is nonrefundable.

RELEASE AND INDEMNITY AGREEMENT

The undersigned warrants that he/she is the parent or legally authorized custodian of the minor identified below (“minor”), and he/she is therefore authorized to grant this release on the minor’s behalf. The undersigned, individually and on behalf of the minor, does hereby release Dynamic Therapy Specialists, LLC (“DTS”) and all of its members, employees, officers and agents, in connection with any and all liabilities, damages, costs, expenses, causes of action and/or claims, including but not limited to attorney’s fees and court costs, in any way resulting from or arising out of any injuries received by the minor or any property damage of the undersigned or the minor as a result of or arising out of the minor’s participating in the classes instructed by Dynamic Therapy Specialists’ employees. The undersigned understands that the camp sessions in which the minor will be engaged may involve the use of tools, materials, equipment, and physical activities that could possibly result in physical injury to the minor. The undersigned also acknowledges and accepts all responsibility to ensure that the minor child is supervised by an onsite adult at all times.Nevertheless, the undersigned, individually and on behalf of the minor, accepts this risk and in order to induce DTS to allow the minor to participate in the session and has agreed to the terms and provisions of this Release and Indemnity Agreement.

Furthermore, the undersigned does hereby agree to indemnify and hold harmless DTS and all of their members, officers, employees and agents from any liability resulting from or in any way arising out of the conduct of the undersigned or the minor, including but not limited to, reasonable attorney’s fees incurred in connection with defending any claims resulting therefrom, any claims brought by the minor or on the minor’s behalf or any claims brought to enforce this agreement.

Signature*

Printed Name:*

Name*

Date*

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STUDENT INFORMATION

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To pay by CHECK:

Parents Information

RELEASE AND INDEMNITY AGREEMENT