Fine Motor Toolbox Program

The Fine Motor Toolbox program will be delivered by an Occupational Therapist. Fine Motor toolbox will be delivered as group sessions. Sessions will allow children to practice and build their fine motor skills, through guided activities and everyday items. Caregiver support maybe required during the sessions.

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Parent / Guardian Name*

First Last

Email*

Phone*

Child's Name*

First Last

Name of FCB Early Learning Coordinator*

Session Date & Time

Please Select One*

Waitlist

Consent

Please read and check all boxes below*

I represent and warrant that my child and I are physically fit enough to partake in fine motor and gross motor exercises, and have no medical, psychological or emotional condition(s) that would prevent us from safe participation in a fine motor virtual session.

All the Occupational Therapist from Foothills Creative Beginnings are Licensed. All information provided during the Fine Motor Toolbox sessions are not a replacement for medical advice from an occupational therapist or other health care professionals. Please consult with a referred occupational therapist to obtain assessment and intervention for developmental issues with your child. The virtual fine motor toolbox sessions do not replace the relationship between an occupational therapist and client in a one-on-one treatment session with an individualized treatment plan based on their professional evaluation.

All activities completed during virtual fine motor toolbox sessions are designed for completion with adult supervision. Please use your own judgment with your child and do not provide objects that could pose a choking hazard to young children. Never leave a child unattended during these activities. Please be aware of and follow all age recommendations on all products used in these activities.

I release and discharge Foothills Creative Beginnings from any and all liability, claim, demand, or action that I may have resulting from injury, illness, death, or damages arisen.

By checking the checkbox and signing this form you consent to the participation of your child in LIVE fine motor sessions with the occupational therapist from Foothills Creative Beginnings effective November 16th, 2021 to June 30, 2022.

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for the use of the selected electronic communications as described below. I understand and accept the risks outlined below to this consent form, associated with the use of electronic communications with the Service Provider. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the Service Provider may impose regarding electronic communications with student families participating in Fine Motor Toolbox sessions. I acknowledge and agree to communicate with the Service Provider or the Service Provider’s staff using these electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I may have regarding the provision of healthcare services through electronic communications can will be answered by the Service Provider.

I authorize the occupational therapist Renée Shilmover to release verbal and written information regarding my child’s participation in the virtual fine motor toolbox sessions to support the efforts of those providing services to my child. The occupational therapist may share my child’s information with other Foothills Creative Beginnings team members.

I understand that I can withdraw my consent at any time through written notice to FCB at Jane.McKeown@foothillscreative.org

Parent/Guardian Signature*

Date*

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