ESU Autism Education Center Fall 2022 Socio-Emotional Learning Groups (In Person)

Parent's Name Parent's Name * First Last
Child's Name *
Child's Age *
Child's Grade Level *
Diagnosis *
Email *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Emergency Contact * First Last
Emergency Contact Phone *
Allergies or Health Concerns *
Legality and Waivers
Services offered through the ESU Autism Education Center will be clearly separate from any school based programming and focused solely on knowledge gaps which impeded individuals rate of success socially and in daily living within the home and community settings. Families will be required to acknowledge, release, and waive all liability of ESU and its staff and students in regards to rate of progress made during the skills building process and acknowledge that service providers are providing services as part of their educational requirements. Families will further be required to acknowledge that all services and skills instruction provided by the Center are supplemental and stand alone to any educational or agency based therapies they currently receive, and therefore, not subject to due process. Center staff will implement non-restrictive positive behavioral support and de-escalation techniques and will not provide any physical support to clients. Parents must stay at clinic/at virtual session and immediately respond if behaviors cannot be de-escalated through verbal prompts, etc. Parents or caregiver is required to be in attendance during the weekly sessions. Additionally, parents acknowledge any data collected during this program can be used for research and publication, with any personal information being e-identified. If there is not an adult present with child either during virtual or in person sessions, the child will not be permitted to participate. By checking the below box, I agree to all of the above. * *

Legality and Waivers
Services offered through the ESU Autism Education Center will be clearly separate from any school based programming and focused solely on knowledge gaps which impeded individuals rate of success socially and in daily living within the home and community settings. Families will be required to acknowledge, release, and waive all liability of ESU and its staff and students in regards to rate of progress made during the skills building process and acknowledge that service providers are providing services as part of their educational requirements. Families will further be required to acknowledge that all services and skills instruction provided by the Center are supplemental and stand alone to any educational or agency based therapies they currently receive, and therefore, not subject to due process. Center staff will implement non-restrictive positive behavioral support and de-escalation techniques and will not provide any physical support to clients. Parents must stay at clinic/at virtual session and immediately respond if behaviors cannot be de-escalated through verbal prompts, etc. Parents or caregiver is required to be in attendance during the weekly sessions. Additionally, parents acknowledge any data collected during this program can be used for research and publication, with any personal information being e-identified. If there is not an adult present with child either during virtual or in person sessions, the child will not be permitted to participate. By checking the below box, I agree to all of the above. * I agree