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Program Registration Form

Memorial Garden

Sunshine Family Prevention Services Registration Form

468 Boyle Road  Port Jefferson Station, NY  11776


Name of programs/service you are registering for 1._________________________2.___________________

 

Child/Teen Name____________________________________ Age ______     Birthdate ______________

 

Male___  Female____  Ethnicity _____________School ______________  Grade________

 

Street Address ____________________________________________________________________________ 

 

Town___________Zip _________   Phone (Home) __________________ (cell)______________________

 

How did you find out about this program? ____________________________________________________

 

Do you want to be on our email list for news/invoicing? Address___________________________________

 

Parent/guardian Name ____________________________________  Relationship to child ____________

 

Emergency Contact ___________________________________________  Phone ___________________

 


Text Box: Rules & Guidelines for all participants Your child must be … Capable of following the basic rules & guidelines of the center Capable of staying in the workshops & groups for the designated time Able to have respect for themselves and others Able to not harm themselves or others in the group As a parent/guardian I do understand that any educational or support program my child attends is not considered therapy or treatment (unless otherwise stated). While I expect benefits from this program, I fully understand that no particular outcome can be guaranteed. I understand I am free to take my child out of the program, but that it would be in the best interest of all to talk with the facilitators and directors first. I understand in this situation I am not entitled to a refund. I understand that if for some reason this program or group is not suitable for my child or the other participants, Sunshine Center will take the following steps: Work with the parent/guardian on resolving these matters Meet with Supervisor and parent/guardian Provide parent/guardian with resources/referrals that may provide my child with the services needed I understand if the child continues to not respond well to the program, this may be a cause for dismissal.

I Understand that there is a 24 hour cancellation policy for all Individual Support Sessions/Counseling.  Any cancellation/missed appointments will be charged a $15.00 fee.

All Program cancellations must given 2 weeks before the program start date notice – Refunds can not be given after that date.  All registration fees are non-refundable

 
Parent/Guardian Sign ________________________________________Date____________

 

 
Permission Form for Sunshine Programs

Please read through this form and initial each section in the appropriate areas

 

I understand that if my child/myself has been registered for a specific Program, the space will be reserved.  In the event that my child/myself will not be attending, I understand I must notify the center immediately.      I understand I will only be refunded if I give notice at least 2 weeks in advance.  I understand that the registration fee is NOT refundable.  Initial ____________

 

I understand that all programs must have a full registration to run.  If the program registration is not full the workshop will not run.  I understand I am entitled to a full refund in the event a program does not run.  Initial ____________

 

I understand in the case of an emergency or a medical problem, Sunshine Center will do their best to reach me.  I give my permission for my emergency contacts and said physicians to make medical decisions that are in the best interest of the said child. 

 

I give my child/myself permission to engage in all program activities including games, snacks, lessons, and photographs/ filming for newspapers/ TV.  I will make the center aware if we do not wish to participate.  Initial ____________

 

I understand my child/myself may be participating in a pre & post tests, evaluations or surveys as part of evaluations or research projects at Sunshine.  Initial ____________

 

I understand if my child/myself is receiving a “Certificate of Completion” we must attend full course.  Initial ____________

 

I understand that the educational groups and support programs my child/myself attends is not considered therapy or treatment (unless otherwise stated).  While I expect benefits from this program, I fully understand that no particular outcome can be guaranteed.

Initial ____________

 

I understand there are basic behavioral rules and guidelines that my child must follow.  And I have reviewed them.  Initial ____________

 

I understand that information can only be given out to others if a Release of Information is given and the participant will be contacted for approval.  Initial ____________

                                    

 

Signed _________________________________________________  Date _____________________

 

 

Parent/Guardian of _______________________________________________________

 

 

 

Sunshine’s Child Assessment Form

The information on this form will help Sunshine to understand your child’s needs and assist us in the development and delivery of successful prevention programs.  All information on this form will be kept completely confidential and will only be accessible to the appropriate staff.  Filling out the form is optional.

 

Child’s Name ______________________________________  Age____Grade _____  DOB________________

 

Your relation to child:    Biological parent _____  Step parent _____  Grandparent _____ 

Adoptive parent  _____   Foster parent _____     Other  _____ (explain)______________

 

What attracted you to this program?_____________________________________________________________

 

What are you hoping for your child to get out of this program?_____________________________________

_______________________________________________________________________________________

 

Family Makeup (Who lives within your household?  e.g. two parents, siblings, etc) ________________________________________________________________________________________

 

Please list any family factors that may be affecting your child (e.g. divorce, trauma, abuse, loss, etc)___________________________________________________________________________________
____________________________________________________________________________________

 

Does your child have any illness, disability, or diagnosis (physical, developmental, mental) that you want to make us aware of?________________________________________________________________________

______________________________________________________________________________________

 

Does your child have any behavior challenges or situations you want to make us aware of? (Anxiety, Aggressive behaviors, etc)___________________________________________________________________________

________________________________________________________________________________________

 

How does your child relate in social situations?___________________________________________________

_______________________________________________________________________________________

 

Please list any specific concerns you have with your child _________________________________________

_____________________________________________________________________

Please describe the best things about your child _________________________________________________

________________________________________________________________________________________

 

Has your child been teased?   Mildly ______         Some _______       Extreme ________

 

How does your child respond to teasing and bullying? ________________________________________

________________________________________________________________________________

 

How does your child handle and express anger? __________________________________________

________________________________________________________________________________

 

What are the areas that are your most concern for your child  _________________________________

_________________________________________________________________

Family Program Registration Form

 

This form must be filled out for all programs, except Summer Programs.

 

New Participants

If you are interested in registering for a program, you need to schedule an IFA—Initial Family Assessment for you and your child with one of our program staff.

 

Program Costs

Sunshine offers payment plans, sliding scale, sponsorship opportunities for all programs (pending funding) we will ALWAYS work with a family and NEVER turn anyone away for financial reasons.