Social Skills Enrollment

Joshua Center for Neurological Disorders changing lives since 1996

A separate form is required for each student.

If you can not finish the form, you may select to 'Save and Continue Later. You will receive an email with a link that you can use from any computer to return to the form to complete at a later time.The link will expire after 30 days.

"*" indicates required fields

Student Information

Student_Name*

Student's Name *

Birthdate*

Student's Date of Birth *

Grade_Level*

Student's Current Grade Level *

Gender*

Student's Gender *

Male

Female

Parent / Guardian Information

You will have the opportunity to enter information for two parent / guardian's.

Parent / Guardian One -

Parent_1_Name*

Parent / Guardian Name *

Parent_1_Address*

Parent / Guardian Address *

Parent_1_Primary_Phone*

Parent / Guardian Primary Phone *

Parent_1_Primary_Phone_Type*

Parent / Guardian Primary Phone Type *

Parent_1_Secondary_Phone

Parent / Guardian Secondary Phone

Parent_1_Secondary_Phone_Type*

Parent / Guardian Secondary Phone Type *

Parent_1_Email*

Parent / Guardian Email Address *

Enter Email Confirm Email

Additional_Parent

Check here if you would like to enter information for a second parent/guardian.

Parent / Guardian Two -

Parent_2_Name*

Parent / Guardian Name

Parent_2_Address*

Parent / Guardian Address

Same as Parent / Guardian 1 Address.

Parent_2_Primary_Phone*

Parent / Guardian Primary Phone *

Parent_2_Primary_Phone_Type*

Parent / Guardian Primary Phone Type *

Parent_2_Secondary_Phone

Parent / Guardian Secondary Phone

Parent_2_Secondary_Phone_Type*

Parent / Guardian Secondary Phone Type *

Parent_2_Email*

Parent / Guardian Email Address *

Enter Email Confirm Email

Please select check boxes below if you agree to the following statements:

My phone number and email may be shared with other parents in my child’s class.

I give permission for teacher training videos to be made with my child during his/her social skills class.

Terms and Conditions

Enrollment
A class fee of $40.00 will be charged to your card on file at the Joshua Center only after your child’s scheduled class. If you have any questions, please contact the Joshua Center. You will be contacted by the teachers at your location with specific schedules.

Cancellation Policy
Occasionally, there will be times that class will need to be canceled due to weather conditions. In the case of cancellation, we will post a notice on the website. It is important that every parent check the website before every class to ensure they have the latest information. www.joshuacenter.com You will also be given your child’s teacher’s phone number at the first class. Please make sure you have that saved in case of questions.

Child Behavior
I agree to stay in the waiting room on my child’s first visit. I also agree to stay at any time the instructors request I stay due to problematic behaviors. If my child is not able to successfully complete a class due to behaviors the instructors will bring my child to the waiting room.

Missed Classes
We understand that sometimes events occur that may cause your child to miss a class. We reserve the right to reschedule or cancel a class for reasons due to insufficient enrollment, holidays, church conflict, inclement weather, or at the Social Skills teachers' professional discretion. You will not be charged for cancelled classes. Our goal is for your child to be successful in our program and progress requires consistency.

Teachers
The Joshua Center conducts a criminal background check as well as a National Sex Offender Registry search on all employees, including Social Skills teachers. Joshua Center Social Skills teachers receive initial training by professionals who have expertise in neurological disorders along with ongoing training for all Social Skills teachers throughout the year. Most Social Skills teachers have experience as either: School Counselors or Social Workers, Special Education/Regular Education/Early Childhood Teachers, Speech and Language Specialists or Autism Specialists.

I understand that I am sent an email reminder about my child’s class on Sunday. It is my responsibility to respond to that email by Wednesday at noon. I understand I will be charged a cancellation fee of $40.00 if I reply that my child will attend and he/she does not show up without letting the Joshua Center know. It’s important to the class success to have a minimum of three students in each class. By signing here, I agree to this.

If you have any questions, please contact the Joshua Center.

Terms_and_Conditions_Agreement*

Select check box if you agree *

I agree to the above Terms & Conditions

Terms_and_Conditions_Signature*

Electronic Signature: *
This will constitute as your signature by filling out this field with your name. An additional signature will be required at check-in time.

Terms_and_Conditions_Date_Signed

Date Signed *

Class Information

Class_Enrollment*

Please enroll my student in the following class *

Social Skills Program

Class_Location*

Please select your preferred attendance location

Release Of Liability

The undersigned releases the Joshua Center for Neurological Disorders, its’ staff members, agents and representatives, officers and employees and its’ Board of Directors from all liability for any injury to the student from participation in the enrolled classes.

Release_Of_Liability_Signature*

Electronic Signature: *
This will constitute as your signature by filling out this field with your name. An additional signature will be required at check-in time.

Release_Of_Liability_Date_Signed

Date Signed

Payment Information

Cash / Check Payments are only accepted if the student is attending classes at the Joshua Center Main Office.

All other locations require student to have credit/debit card on file.

You will only be charged for classes your child attends, with the following exception: If you respond that your child will be at class and he/she is not there and we are not told, you will be charged.

Social Skills Registration Payment: We will be receiving funding through:

I will be paying for each class and will need a receipt for each class.

Enter Coupon Code:

Thank you for entering a valid coupon code. You will get your third class free!

Select Payment Method:

Check - Only If Attending Classes At Joshua Center Main Office

Credit Card / Debit Card - All Other Locations

Do you need a receipt?

I will need a receipt after each class.

Check Information

If paying by check, I understand that I must pay no later than the day of class. If I am more than two classes behind in payment, I understand that my child may not participate until account is brought current.

Please send check to:
Joshua Center for Neurological Disorders
1010 Carondelet Drive, Suite 120
Kansas City, MO. 64114
Please note student's name in the "memo field" of the check.

Credit / Debit Card Information

Card on File*

I understand I need to call 816-763-7605 to set up payment information before the first class.

Hidden

Cardholder Name

Hidden

Billing Address:

Same as Parent/Guardian Address?

Hidden

Card Number

Hidden

Expiration Date

Hidden

Additional Comments:

CAPTCHA

Social Skills Enrollment

Student Information

Parent / Guardian Information

Parent / Guardian One -

Parent / Guardian Two -

Terms and Conditions

Student Diagnosis Information

Class Information

Release Of Liability

Payment Information

You will only be charged for classes your child attends, with the following exception: If you respond that your child will be at class and he/she is not there and we are not told, you will be charged.

Check Information

Credit / Debit Card Information

Additional Comments:

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