Children’s Program Registration Form | Ashley Addiction Treatment

Patient / Guardian Name:(Required)

First Last

Parent / Guardian Email:(Required)

Work Phone:(Required)

Home Phone:(Required)

Home Street Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do we have your permission to add you to our mailing list (we do not sell our lists)?(Required)

Yes

No

Attendee Info(Required)

Child/Children’s Names

Age/Birthday

Name of Parent(s) Guardian(s) Attending:

Please note, all children registered for the program must be 7-12 years old. Please list the name(s) of the child(ren) attending, age / birthday and name of parent(s) or guardian(s) attending

Has the child displayed any aggressive physical or verbal behaviors?(Required)

No

Yes (Please explain)

Explanation: Aggressive physical or verbal behavior(Required)

What were the circumstances surrounding the episode?(Required)

Was there a response/consequence to the behavior and what was?(Required)

No

Yes (Please explain)

Explanation: Consequence for physical / verbal behavior(Required)

What would you like from the program?(Required)

How did you hear about the Children’s Program?(Required)

Will you be staying at a hotel, bed and breakfast, etc. while participating in the program?(Required)

No

Yes

If yes, where will you be staying?(Required)

Other comments you would like the Children’s Program staff to know to better assist your child:(Required)

The best phone number to reach you or another family member (provide name) in case of an emergency:

(Emergency Contact Name)(Required)

(Emergency Contact Phone Number)(Required)

Person filling out this form: (Name)(Required)

Person filling out this form: (Relationship with Child/Children)(Required)

Ashley Addiction Treatment Children’s Program Release Form

I am aware that participation in Ashley’s Children Program involves doing some physical activities in doors and in pleasant weather, outside. Therefore my participating children must be sufficiently free of medical or physical conditions which might create undue risk. I am aware that even though the games and activities involved in the program are low-risk that there is still a potential opportunity for injury to my children and I acknowledge that I am aware of and assume all risks and wish my children to participate in the program activities. As part of the consideration for my children’s participation in the Children’s Program at Ashley Addiction Treatment, I agree to indemnify and hold harmless Ashley Addiction Treatment and officers from any and all liability incurred as a result of participation by myself or my child. I also agree that the terms hereof shall serve as a release and assumption of risk for heirs, executors and administrators, and for all members of my family.

Medical Information: It is necessary for us to know if your child/children has/have any medical considerations. If not, write “no”, if so, please write “yes” and describe in detail. You may write longer responses on the back of this form. Please be specific with each child.

Child’s/Children’s Name:(Required)

Chronic medical conditions (i.e. Diabetes, Asthma, Seizures, etc):(Required)

Allergic reactions (i.e. Insect bites, stings, or poison oak, or to any medications):(Required)

Any surgeries, sprained muscles, or broken bones within the past 12 months?:(Required)

*PLEASE BRING ANY EMERGENCY MEDICATIONS THAT MIGHT BE NEEDED WITH YOU. (Asthma meds, epi pen etc. These may only be administered by a parent/guardian, not Ashley staff)

Please provide the name and number of an emergency contact.

Emergency Contact Name:(Required)

Telephone Number(s):(Required)

Authorization to transport and treat a minor: In the event I cannot be reached in an emergency, I hereby give permission to the person named as emergency contact to transport and authorize medical treatment of my child/children.

Signature (Parent/legal guardian must sign for persons under 18)(Required)

Please Type Name Here(Required)

First Last

Ashley Addiction Treatment Children’s Program Participant Agreement

Child’s/Children’s Name:(Required)

As a participant of the Children’s Program, I agree to abide by the following policies and procedures:

I will be free of any mind-altering chemicals during participation in the program.
I will maintain strict confidentiality regarding whom and what I see and hear while participating in the Children’s Program. I will expect the same from others regarding my own confidentiality.
I will be on time to all meetings and activities.

Signature of Witness(Required)

Please Print Name Here

Grievance Procedure

The Staff of Ashley Inc. strive to treat everyone with respect, dignity and in a professional manner. Should you find yourself in a disagreement with a staff member, or are concerned about the care given to your loved one, there are steps you can follow to resolve the issue.

Call the Clinical Director to discuss your concerns.
You may be asked to place your concerns in writing to the Clinical Director’s attention. A written response will be returned to you within three business days indicating receipt of your written concerns. A written resolution to your concern will be returned to you within five business days following the original correspondence from the Clinical Director.
If this does not lead to a resolution of your concerns, the Clinical Director will arrange for you to talk to the Chief Executive Officer.
You also have the right to register a grievance with the Maryland Department of Health and Mental Hygiene and JCAHO.