Educational Support Enrollment Forms Contact Information

Enrollment Forms / Part 1: Contact Information

* Indicates required field

Child's Name *

First

Last

Child's Date of Birth *

Child’s siblings/name(s) and ages *

Parent(s)/guardian(s) name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent(s)/guardian(s) name Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parental Release

PARENTAL RELEASE: I, the undersigned, authorize my child named above to participate in Educational Support sessions with Marjorie Rehbach where there will be a balance of hands-on activities, exercises, and art, with appropriate touch where necessary, for helping with reflex and sensory integration. All work will proceed at your child’s comfort pace. The intention is to offer gentle enhancement without forcing her/him to do anything that does not feel safe or comfortable. I agree to attending sessions with my child, doing follow-up activities at home, arriving on time, (or giving 24 hours’ notice when needing to reschedule due to unforeseen circumstances). If no notice is given, there will be a full charge for the scheduled session.) Exception: When illness occurring during the school day, or an accident, prevents attendance. *

Yes

SESSION INFORMATION AND RELEASE. The child in my care and I are participating in Educational Support sessions, with Marjorie Rehbach as facilitator. I understand that I will be present at all times during my child’s Integrative Movement sessions. I understand we will be invited to do various movement activities and that we can choose to forego any activity, at any time, for any reason. I understand that we are in charge of our experience and that if anything should feel uncomfortable we will say so. I understand that none of the movements should cause pain or injury and it is our responsibility to adapt all movements to our ability and comfort level. I understand that appropriate, light touch may be used with my child’s permission and my permission, for the purpose of facilitating the activities in the session. I understand and agree that no medical diagnosis, prognosis, or treatment is expressed or implied in any session and any information given is not a substitute for diagnosis and/or treatment from a qualified healthcare professional. I agree to this statement for myself and on behalf of my child as a condition of our participation in the session with Marjorie Rehbach: Nothing in this session should be interpreted as medical advice. I will consult with our healthcare provider if I have questions about doing movement. I expressly waive and release any claim that I may have—at any time, for any injury or any infection—against Marjorie Rehbach. *

Yes

Information Sharing and Information Release Form

INFORMATION SHARING AND INFORMATION RELEASE FORM: I, the undersigned, give my permission to Marjorie Rehbach, to discuss and exchange information, and to forward any reports or evaluations regarding my child to my child’s class teacher. In addition, Marjorie Rehbach might need to contact other teachers, therapists, medical professionals, etc., who have worked with your child in the past. Please list names and contact info of teachers, therapists, medical professionals, etc, and that you are granting your permission to contact. *

Yes

Class Teacher *

Other Teacher(s) *

Medical Professionals *

Other *

Comments regarding information sharing/information release form *

The Process

Fill out and return enrollment forms and payment to Marjorie.
Initial Meeting: Parents and Marjorie meet, discuss my approach to educational support, address questions, and explore how we can work together to support family and child.
Assessment Lesson: Marjorie, a parent, and the child will go through a playful movement journey to help identify what is going well for the child and what could be even better.
Written Report: Marjorie will translate the results of the assessment lesson into what is going well and what could be even better and suggest a plan of support.
Post Assessment Meeting: The written Assessment Report will be shared with parents and a plan for working together will be proposed.
If everyone would like to go forward, with a plan for 12 weeks of lessons and some homework, a schedule is then set up and payment would be accepted at this time or at the first lesson.

Comments *

Financial Commitment

FINANCIAL COMMITMENT: I, the undersigned, understand that the financial commitment is as following. Please check carefully, and acknowledge and select options. Assessment, Consultation and Final Report Fees are $200, due with your enrollment forms. After our post-assessment conversation, you may decide to sign up for a series of 12 prepaid sessions of 1 hour each, meeting 1–2 times per week. The cost is $100 per hourly session. 12 sessions X $100 = $1200. *

Yes

Your preferred method of payment (please specify) *

Cash Check Mobile pay (apple pay, google pay, Venmo, etc.) Credit/debit card

Signature(s)

Name *

First

Last

Electronic Signature. By clicking/choosing 'yes' below, I confirm that I have stated true and factual information about myself and my (our) child in this enrollment form and that it is accurate to the best of my (our) knowledge. *

Yes

Signature(s)

Name *

First

Last

Yes

Once you have completed filling in the form please click/tab the SUBMIT button below. The information will be submitted and you will be directed back to the Enrollment Forms page. Please continue with Enrollment Forms / Part 2.

Educational Support with Ms. Marjorie

A Wholistic Approach to Strengthen the Foundations of Behavior and Learning

Enrollment Forms / Part 1: Contact Information

Parental Release

Information Sharing and Information Release Form

The Process

Financial Commitment

Signature(s)

Signature(s)

Educational Support with Ms. Marjorie

A Wholistic Approach to Strengthen the Foundations of Behavior and Learning

Enrollment Forms / Part 1: Contact Information

Parental Release

Information Sharing and Information Release Form

The Process

​Financial Commitment

Signature(s)

Signature(s)

Financial Commitment