Registration Package

Participant Information
Medications, Allergies, or Special Diets
Does your child have any known allergies or sensitivities to foods? Is your child currently on a special dietary or nutritional program?
If YES, please explain in detail below. If NO, please write NOT APPLICABLE:
Please list current medications and supplements.
Please enter a phone number in the format 123-456-7890
Contact Information
Please enter a phone number in the format 123-456-7890
Please enter a value in the format A1B 2C3
Father/Guardian's Information
Please enter a phone number in the format 123-456-7890
Please enter a phone number in the format 123-456-7890
Mother/Guardian's Information
Please enter a phone number in the format 123-456-7890
Please enter a phone number in the format 123-456-7890
Emergency Contact's Information
Please enter someone different than above.
Please enter a phone number in the format 123-456-7890
Diagnoses
If YES, please list below. If NO, please write NOT APPLICABLE:
Sensory Overwhelm
Does your child experience sensory overwhelm? (For example, loud sudden noises may cause a sensory overwhelm and in turn cause an uncontrollable outburst) If so, please explain possible triggers and/or sensitivities; how you deal with your child's reaction and if your resolution has been effective.
If YES, please explain below. If NO, please write NOT APPLICABLE:
Concerns and Goals
Do you have any parental concerns or any other problems you would like to be addressed, or anything specific that you would like to achieve? This information is very helpful for your therapists, so we thank you for taking the time to complete.

Declaration of Compliance - COVID-19

All participants entering the facility must comply with this declaration.

By signing this document, I agree to follow club staff directives, and engage with all club requirements in Club Aviva’s COVID-19 Safety Plan. Additionally, I hereby acknowledge and agree to respect the following information outlined in this document:

  1. Sickness
    • I will stay home if I am unwell, or if someone in my household is unwell, or is displaying the following symptoms:
      • Fever and chills
      • Cough
      • Shortness of breath
      • Sore throat and painful swallowing
      • Stuffy or runny nose
      • Loss of sense of smell
      • Headache
      • Fatigue
    • I confirm that I have not knowingly been in contact with a person that has a confirmed or suspected case of COVID-19.
    • I agree to complete a routine daily screening process prior to entering my club.
    • I confirm that I have not travelled outside of Canada in the last 14 days. Additionally, I confirm that I have not been knowingly exposed to someone who has travelled outside of Canada in the last 14 days.
    • I acknowledge there are inherent risks associated with participating in activities. By attending club activities, I understand and assume all risks associated with potential exposure of COVID-19.
  2. Personal Hygiene
    • I agree to follow all personal hygiene requirements set out by my club, including but not limited to: frequent hand-washing and sanitizing, coughing and sneezing into my sleeve, etc.
  3. Physical distancing
    • I agree to practice safe social interactions, by maintaining a minimum distance of two meters between myself and others.
  4. Environmental hygiene
    • I agree to adhere to all club cleaning requirements.
  5. Physical modifications
    • I understand that equipment may be moved in order to facilitate safe social interactions and physical distancing.

Additionally, I understand and agree that if I do not adhere to the requirements set out by my club, I may be asked to leave the club activity in order to protect the health and safety of all involved.

This Participant Declaration of Compliance will remain in effect until GBC determines it is no longer required, based on viaSport, PHO, and WorkSafeBC requirements.

Please check the box below to indicate you fully understanding the content, meaning, and impact of this release.

Photo & Video Release Waiver

On occasion, photos, and video/DVD recordings may be taken during the course of Empowering Steps Sessions, Intensives, Year End shows, events, etc. Please be aware that the participant’s photos and/or recordings may be used for future promotional purposes, training or research purposes.

Please check the box below to indicate you fully understanding the content, meaning, and impact of this release.

I grant permission to Club Aviva Recreation Ltd. and/or Delta Gymnastics Society and its agents or employees to use photographs and/or video/DVD and audio taken of my child. Furthermore, I authorize the use of images of my child for all program promotion, materials, and any other purposes in connection with the program deemed appropriate and necessary by Club Aviva and/or Delta Gymnastics Society. I agree to release, defend, and hold harmless Club Aviva Recreation Ltd. and/or Delta Gymnastics Society and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from any claim, damages, or liability arising from or related to the use of the photographs/video.

Research Release

Empowering Steps is a research-based program. Please check the box below to consent to the use of statistics and data on your child for research purposes. For statistical analysis, we may request the help of statisticians or other researchers who will respect the same rules of privacy and confidentiality. All analyses will be conducted on anonymized datasets where it is impossible to recognize any participant. In the event any results are published, it will be done so in a way that does not identify you or your child unless permission to do so has been obtained. We may also share the data with other researchers so that they can check the accuracy of our conclusions but will only do so if we are confident that your confidentiality is protected.

I consent to the use of my child’s data and information for research purposes. Only Club Aviva staff will have access to any information that could identify my child. I give permission for UBC researchers to work on documents generated by Club Aviva staff during Empowering Steps programs. This data will be extracted and all personal information removed before conducting the statistical analysis.

Empowering Steps Fee Structure

Payment Category

Length of Session

Per Session

10 Months

equal payments (private payments only)

per week

 

In full

Sept 1 - Jun 1 x 10 each

CATEGORY 1 (GST Exempt) 45 min $90.00 $3150.00 $315.00
1 hr $120.00 $4200.00 $420.00
CATEGORY 2 (with GST) 45 min $94.50 $3307.50 $330.75
1 hr $126.00 $4410.00 $441.00

*Fees do not include any applicable taxes. Clients who have 3rd party funding or a medical referral from a medical practitioner, such as a physician, social worker, registered psychologist or nurse may be exempt from GST.
*If you attend multiple sessions per week please combine the appropriate totals/payments
*Group rates are available upon request to parents/guardians with a participant who has been recommended for a group program.

Fees include

The fee covers the 1:1 client time as well as the reserved time slot for the 10 month time period. It also includes access to a supervisor when your child requires 2:1 assistance for extra support. In January and June semiannual assessments are done. Each assessment requires your child’s therapist, a supervisor and a minimum of 1 hour in the gym and is included in the ES Service rates. Everyday therapists spend a minimum of 30 minutes on daily notes, session set up and preparation. The ES Team also meets once a week for 2 hours to discuss progress/goals/treatment plans etc. Facility and equipment costs are also included. Fees also include the GBC and Club Membership Fee (please see below).

GBC and Club Membership

Is included in your fees. This mandatory membership is (value over $60.00) is valid from September 1st through August 31st each year. The annual membership includes Gymnastics BC (GBC) insurance, 10% off Club Aviva and Empowering Steps t-shirts and hoodies.

Third Party Billing (Automatic Funding)

In order to set up automatic funding or third party billing from an organization, Club Aviva must receive a confirmation letter from the organization that outlines the dates and amounts that the funding is available for. The customer is responsible for setting up funding with the organization. Until the confirmation letter has been received, the customer may be responsible for making the monthly payments using the post-dated cheques method of payment. Once payment has been received from the funding organization, we can reimburse the customer for that amount and return the remaining post-dated cheques for the term.

  1. Autism Funding Unit (AFU) at the Ministry of Children and Family Development (MCFD):
    Club Aviva invoices the AFU at the MCFD for all services based on our hourly rate. If you receive funding from the AFU, please obtain a MCFD Autism Funding “Request to Pay” form (CF0925) from the ES Office, as we have already correctly completed the information needed for the “Service Provider” section which includes all of our services. You will need to complete the rest of the form, send directly to the MCFD or we will forward to MCFD on your behalf. If you send the form directly, please provide the ES Office with a copy for our records, in order to commence services. Incorrect forms result in delays, so please email esmt@clubaviva.ca if you have any questions.
  2. Other Funding Agencies:
    If you receive funding from a different agency other than the AFU (MCFD), a confirmation letter must be given to the ES Office prior to your child starting services.

Post-Dated Cheques/EFTs

For clients who do not receive third party funding, post -dated cheques or an EFT for the entire year from Sep 1-Jun 1, are due upon registration and need to be dated for the first of each month. Please make cheques payable to Club Aviva Recreation Ltd. Cheques/EFTs will be processed on the first of each month and detailed invoices will be emailed at the end of each month.

Cancellation policy

Empowering Steps is not a per/session service. It is a 10-month program, operating September – January and February - June that involves a lot of administrative, preparatory, and consultative work outside of sessions. When your child is absent, your therapist is reviewing their log book, preparing for their next session, consulting with other therapists/supervisors, re-evaluating the effectiveness of their current behavior plan/program delivery, as well as preparing a debrief on your child for discussion at weekly ES collaborative meetings. For this reason, all scheduled programming will be charged in full. If you miss 3 sessions in a row without notification, or miss more than 25% of your scheduled program for more than 2 consecutive months, Club Aviva reserves the right to remove your child from the schedule and offer the spot to a client on the waitlist.

Missed In-Person Private Lessons due to Student Illness during COVID-19

As per Club Aviva’s COVID-19 Safety Plan, clients should not enter our premises if they are experiencing any symptoms of COVID-19. Clients who cannot attend their in-person session due to COVID-19 symptoms or any other respiratory illness, can arrange with their therapist or the ES Office with at least 4 hours advance notice, to attend their regularly scheduled private session online virtually. Clients who are too ill to attend the private session online, or whose therapist does not offer virtual to their client online, will be offered a make-up session. Clients will be limited to three make-up private sessions per season (September – June) due to illness.
Note: this policy does not apply for in-person Sep-Jun group sessions.
Extreme circumstances may be reviewed on a case by case basis.

Program Withdrawal

If you are permanently withdrawing for medical reasons, a note from the child’s medical practitioner must be provided in order to receive a refund for remaining sessions. Otherwise, one month’s written notice from the 1st of the month, must be given for withdrawal from the program and payments will be due for one month after the customer gives notice.

Assumption and acknowledgment of risks for minors

Re: use of premises and equipment of Club Aviva Recreation Ltd and Delta Gymnastics Society

To: the above clubs, operating as Delta Gymnastics Society and Club Aviva Recreation Ltd. (referred to in this document as the named clubs) and Gymnastics BC, and the directors, officers, employees, representatives, officials, landlord and agents of both organizations

I have read the guidelines and rules issued for the use of the named clubs’ premises and equipment, which I understand, and I agree to be bound by them. I further agree to acknowledge that:

  1. The rules and guidelines governing the use of the premises and equipment are solely for that purpose, that is, for the use of gymnastics activities, and it remains my sole responsibility to act and govern myself in such a manner as to be responsible for my own safety;
  2. I am aware of the risks inherent in participating in gymnastics activities and the use of gymnastics premises, facilities and equipment and I assume the risks and waive notice of all conditions, dangers or otherwise relating to or arising out of such use.
I/We agree to uphold this contract between myself/ourselves, my/our child and Club Aviva Recreation Ltd. And abide by the terms set out therein, including but not limited to, the Cancellation Policy, Program Withdrawal Policy, Program Policies and Procedures, and the Assumption and Acknowledgment of Risks for Minors.
Please print the name(s) of parent(s) and/or guardian(s) that are signing.

Session Time Request

Empowering Steps Programs

Behavioural Intervention
We will schedule on a “first come, first served” basis
Saturday and Sunday 9:00 am to 1:00 pm only
:
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We cannot guarantee therapists
Movement Therapy
We will schedule on a “first come, first served” basis
Saturday and Sunday 9:00 am to 1:00 pm only
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We cannot guarantee therapists
ES Home School Program
We will schedule on a “first come, first served” basis
:
:

Duration: Inquire within to discuss session duration

We cannot guarantee therapists

Empowering Steps Specialized Programs

ES Bike Riding (September only)
Sessions are available between 9am and 4pm only
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:
ES Rock Climbing at Climb Base5
Sessions are available between 10am and 12pm or 2pm and 4pm
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Occupational Therapy with Luc Jeanneau

Group occupational therapy sessions
Sessions are Mondays, between 12 and 3 pm

Duration: Inquire within for session duration

One-to-one sessions with OT
Sessions are Mondays, between 9 and 11:30am
:
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One-to-one interactive sessions with ES therapist assistant
We will schedule on a “first come, first served” basis
Saturday and Sunday 9:00 am to 1:00 pm only
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We cannot guarantee therapists

Speech Therapy with Suzy Spence

Group speech sessions
Sessions are Tuesdays between 11 am and 2 pm
One-to-one interactive sessions with ES therapist assistant
We will schedule on a “first come, first served” basis
Saturday and Sunday 9:00 am to 1:00 pm only
:
:
:
We cannot guarantee therapists

Music Therapy with Joney Poon

Group music sessions
Sessions are Wednesdays between 11 am and 12 pm
One-to-one sessions
We will schedule on a “first come, first served” basis
Wednesdays between 9:45am and 10:30am or 1:00pm and 7:00pm
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