Please note: Your 2025-2026 registration package is a 2 part process. Both sections must be filled to accommodate your session time request.

Part 1: JaneApp registration package

Part 2: Activity Messenger 2025-2026 Service Request

Respondent completing this form (not the participant)

You will receive a confirmation by email.

First name *

Last name *

Pronouns

Email *

Mobile

Participant information

First name *

Last name *

Date of birth

Participant gender

Participant pronouns

ex. he/him/his, they/them, she/they

Participant pronouns

Thank you for also completing your annual registration on JaneApp. Please also keep us updated with regard to your preferences for the following:

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, Symington Symbiotic Foundation 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 Recreation Ltd. and Symington Symbiotic Foundation. I agree to release, defend, and hold harmless Club Aviva Recreation Ltd, Symington Symbiotic Foundation 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. I do not grant permission x Clear

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 and SSF staff will have access to any information that could identify my child. I give permission for researchers to work on documents generated by Club Aviva and SSF staff during Empowering Steps programs. This data will be extracted and all personal information removed before conducting the statistical analysis. I do not consent to the above x Clear

Fee Structure *

ES Behavioural Intervention (gym or pool): $120/hour
ES Movement Therapy (gym or pool): $120/hour
ES Physio-integrated Therapy: $120/hour + $75/month for virtual PT monthly check-in
ES Speech-integrated Therapy: $187.50/hour
Speech Therapy 1:1 (in classroom setting): $150/hour

Please note: An additional 15 minutes will be billed in conjunction with each booked session time to account for indirect time associated with the session (post-session debrief with parents, charting and biannual assessment reporting); excluding Physio Therapy 1:1, social groups and Summer BI Intensives. For example, a 45 minute BI session will be billed as 1 hour and will include 45 minutes of direct time with the therapist and 15 minutes of indirect time, for a total of $120.

I understand and agree to the fee structure as outlined above x Clear

Session Time Request

Would you like to schedule multiple Empowering Steps services? *

Yes No x Clear

Which Empowering Steps services would you like to register for? *

Gym Based- Empowering Steps Behavioural Intervention/ Movement Therapy Empowering Steps Aqua Therapy SLP-integration PT-integration (+$75/monthly check-in) 1:1 SLP (classroom-based) - separate booking Empowering Steps Trampoline Group x Clear

Which Empowering Steps services would you like to register for? Select all that apply: *

Select all Clear all

Which Empowering Steps services would you like to register for? Select all that apply: Gym Based- Empowering Steps Behavioural Intervention/ Movement Therapy Empowering Steps Aqua Therapy PT-integration (+$75/monthly check-in) Empowering Steps Trampoline Group SLP-integration 1:1 SLP (classroom-based) - separate booking

*Please note that SLP- and Physio-integrated services are conducted by an ES therapist with weekly (SLP) or monthly (PT) check-ins from either our Speech and Language Therapist or Physiotherapist.

1. Empowering Steps BI/MT (base program) at Club Aviva

If you are interested in incorporating Rock Climbing into your Gym session, please speak with your therapist.

Preferred duration *

Preferred duration

Preferred frequency *

Preferred frequency

Preferred Therapist if applicable *

Candice Natasha Jamie Connor Tyanna Ryan None x Clear

1st Choice: Preferred day for gym sessions at Club Aviva *

Will schedule on a "first come, first served" basis.

1st Choice: Preferred day for gym sessions at Club Aviva

1st Choice: Preferred time for gym sessions at Club Aviva *

Will schedule on a "first come, first served" basis.

1st Choice: Preferred time for gym sessions at Club Aviva

If your first choice is unavailable, what other time would you like for gym sessions? (Please Indicate in box below) (eg. Monday at 1pm, Thursday at 4pm, Friday at 10am) *

If your first choice is unavailable, what other time would you like for gym sessions? (Please Indicate in box below) (eg. Monday at 1pm, Thursday at 4pm, Friday at 10am)

2. Physical Therapy Integration

Use this time request for Physio-Integrated BI/MT ES services conducted by an ES therapist, with monthly check-ins by our Physiotherapist. Check-ins currently take place virtually, and check-in sessions will be filmed for review by our Physiotherapist. Monthly check-ins are an additional $75/each.

Are you currently a PT client? *

Yes No x Clear

PT-integrated session (for new clients)

Please contact Courtney at pt@symingtonfoundation.ca to schedule a PT initial assessment

See our PT service page here: https://empoweringsteps.ca/services/physiotherapy

Preferred duration *

Preferred duration

Preferred frequency *

Preferred frequency

Preferred Therapist if applicable *

Candice Natasha Jamie Connor Tyanna Ryan None x Clear

1st Choice: Preferred day for PT-integrated sessions *

Will schedule on a "first come, first served" basis.

1st Choice: Preferred day for PT-integrated sessions

1st Choice: Preferred time for PT-integrated sessions *

Will schedule on a "first come, first served" basis.

1st Choice: Preferred time for PT-integrated sessions

If your first choice is unavailable, what other time would you like for PT-integrated sessions? (Please indicate in box below) (eg. Monday at 1pm, Thursday at 4pm & Friday at 10am) *

If your first choice is unavailable, what other time would you like for PT-integrated sessions? (Please indicate in box below) (eg. Monday at 1pm, Thursday at 4pm & Friday at 10am)

3. Speech Therapy Integration

Use this time request for SLP-Integrated BI/MT ES services conducted by an ES therapist with 15-min per-session check-ins by our Speech & Language Therapist.

1st Choice: Preferred day for SLP-integrated sessions *

Will schedule on a "first come, first served" basis. Please note that SLP-integrated sessions are available Mon-Fri only.

1st Choice: Preferred day for SLP-integrated sessions

1st Choice: Preferred time for SLP-integrated sessions *

Will schedule on a "first come, first served" basis.

1st Choice: Preferred time for SLP-integrated sessions

If your first choice is unavailable, what other time would you like SLP-integrated sessions? (Please indicate in box below) (eg. Monday at 1pm, Thursday at 4pm, Friday at 10am) *

If your first choice is unavailable, what other time would you like SLP-integrated sessions? (Please indicate in box below) (eg. Monday at 1pm, Thursday at 4pm, Friday at 10am)

Preferred duration *

Preferred duration

Preferred frequency *

Preferred frequency

4. Other services

Use this section to indicate whether you are interested in any of our other non-gym-based services

1:1 SLP (classroom-based)

Please contact Tiffany at slp@symingtonfoundation.ca to inquire about 1:1 SLP services.

See our SLP service page here: https://empoweringsteps.ca/services/slp

Empowering Steps Trampoline Group

Please select the time(s) that would work? Select all that apply *

Please select the time(s) that would work? Select all that apply Friday 3:30-4:30 PM Friday 4:30-5:30 PM

Aqua (Pool) BI/MT

Please contact Angela at esadmin@clubaviva.ca to inquire about BI/MT ES services conducted by an ES Aqua Therapist at Poirier Sports & Leisure Complex.

Pool is only available on Monday and Tuesday after 3:00pm

1st Choice: Preferred day for sessions with Candice *

Monday Tuesday Wednesday Thursday Sunday x Clear

Preferred Time for Monday with Candice *

Will schedule on a "first come, first served" basis.

Preferred Time for Monday with Candice

Preferred Time for Tuesday with Candice *

Will schedule on a "first come, first served" basis.

Preferred Time for Tuesday with Candice

Preferred Time for Wednesday with Candice *

Will schedule on a "first come, first served" basis.

Preferred Time for Wednesday with Candice

Preferred Time for Thursday with Candice *

Will schedule on a "first come, first served" basis.

Preferred Time for Thursday with Candice

Preferred Time for Sunday with Candice *

Will schedule on a "first come, first served" basis.

Preferred Time for Sunday with Candice

1st Choice: Preferred day for sessions with Natasha *

Tuesday Wednesday Thursday Sunday x Clear

Preferred Time for Tuesday with Natasha *

Will schedule on a "first come, first served" basis.

Preferred Time for Tuesday with Natasha

Preferred Time for Wednesday with Natasha *

Will schedule on a "first come, first served" basis.

Preferred Time for Wednesday with Natasha

Preferred Time for Thursday with Natasha *

Will schedule on a "first come, first served" basis.

Preferred Time for Thursday with Natasha

Preferred Time for Sunday with Natasha *

Will schedule on a "first come, first served" basis.

Preferred Time for Sunday with Natasha

1st Choice: Preferred day for sessions with Jamie *

Monday Tuesday Wednesday x Clear

Preferred Time for Monday with Jamie *

Will schedule on a "first come, first served" basis.

Preferred Time for Monday with Jamie

Preferred Time for Tuesday with Jamie *

Will schedule on a "first come, first served" basis.

Preferred Time for Tuesday with Jamie

Preferred Time for Wednesday with Jamie *

Will schedule on a "first come, first served" basis.

Preferred Time for Wednesday with Jamie

1st Choice: Preferred day for sessions with Connor *

Tuesday Wednesday Thursday Friday Saturday x Clear

Preferred Time for Tuesday with Connor *

Will schedule on a "first come, first served" basis.

Preferred Time for Tuesday with Connor

Preferred Time for Wednesday with Connor *

Will schedule on a "first come, first served" basis.

Preferred Time for Wednesday with Connor

Preferred Time for Thursday with Connor *

Will schedule on a "first come, first served" basis.

Preferred Time for Thursday with Connor

Preferred Time for Friday with Connor *

Will schedule on a "first come, first served" basis.

Preferred Time for Friday with Connor

Preferred Time for Saturday with Connor *

Will schedule on a "first come, first served" basis.

Preferred Time for Saturday with Connor

1st Choice: Preferred day for sessions with Tyanna *

Friday Saturday x Clear

Preferred Time for Friday with Tyanna *

Will schedule on a "first come, first served" basis.

Preferred Time for Friday with Tyanna

Preferred Time for Saturday with Tyanna *

Will schedule on a "first come, first served" basis.

Preferred Time for Saturday with Tyanna

1st Choice: Preferred day for sessions with Ryan *

Saturday x Clear

Preferred Time for Saturday with Ryan *

Will schedule on a "first come, first served" basis.

Preferred Time for Saturday with Ryan

If your first choice is unavailable, what other time would you like sessions? (Please indicate in box below) (eg. Monday at 1pm, Thursday at 4pm, Friday at 10am) *

If your first choice is unavailable, what other time would you like sessions? (Please indicate in box below) (eg. Monday at 1pm, Thursday at 4pm, Friday at 10am)

Method of Payment

Cancellation Policy *

Regular MT, BI, or integrated sessions:

Four missed sessions will be allowed at no charge if notified before 8:00am on the day of the missed session. Any no shows or late cancellations will be billed in full. Any missed sessions exceeding this will be billed in full.

Exemptions:

Exemptions to these policies may be considered for medical reasons with approval from the management team. Extended absences or program withdrawal will require 1-month's notice.

I have read and agree to the cancellation policy as outlined above x Clear

Payment Information *

Please indicate below how you would like to be billed for your ES services.

If you would like to use multiple funders/methods of payment, please check all that apply and provide details in the "Other" text box (ex. SLP to At home, PT to Pacific Blue Cross and BI to Autism funding). Please clarify amounts to bill to each funder, and we will do our best to accommodate (ex. $60 to At home and $60 private).

Select all Clear all

Payment Information Private - in full Private - monthly via card on file (autopay) Private - monthly post-dated cheques MCFD - Autism funding At-Home funding CKNW Other

Other payment method:

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