Joshua Center for Neurological Disorders

Life Skills for High School and Young Adults Enrollment

A separate form is required for each student.

Student Information
Student Name:*
First Last
Birthdate:*
Current Grade Level:*
Gender:*
- Male
- Female
Parent / Guardian Information
Parent / Guardian 1:
Name:*
First Last
Address:*
Street Address City State ZIP Code
Primary Phone:*
Secondary Phone:
Email Address:*
Enter Email Confirm Email
- Check here if you would like to enter information for a second parent/guardian.
Parent / Guardian 2:
Name:*
First Last
Address:*
Same as Parent / Guardian 1 Address.

Street Address City State ZIP Code
Primary Phone:*
Secondary Phone:
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.

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Terms & 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.

Child's 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.

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.

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 Monday. If I have not replied via email or phone call by noon on Wednesday of that week, I know that the Joshua Center will assume my child is attending the class. If my child does not attend that week, and I did not reply by noon on Wednesday, I understand I will be charged a cancellation fee of $40.00. I understand that this is because it is important to communicate to the Joshua Center so they may plan accordingly for each class. By signing here, I agree to this.

If you have any questions, please contact the Joshua Center.
Select check box if you agree:*
- I agree to the above Terms & Conditions
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.
Date Signed:
MM slash DD slash YYYY

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Class Information
Please enroll my student in the following class:
- Life Skills for High School and Young Adults Program
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.
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.
Date Signed:
MM slash DD slash YYYY
Payment Information
You will only be charged for the classes that your student attends.
Enter Coupon Code:
Thank you for entering aa valid coupon code. You will receive your third class free of charge!
Select Payment Method:*
- Check
- Credit Card / Debit Card
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 Understanding*
- 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?

Street Address City State ZIP Code
Hidden
Card Number*
Hidden
Expiration Date*
Hidden
*
Additional Comments:
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Phone
This field is for validation purposes and should be left unchanged.