COMMUNITY LIVING VICTORIA Autism Services Program 3861 Cedar Hill X Rd. Victoria, V8P 2M7 Phone: (250) 477‐7231 ext. 237 Fax: (250) 477‐6944 [email protected] 2016 Social Skills Groups Registration Form and Contract PLEASE NOTE: For registration to be confirmed, the following items must be completed:  this registration form, signed and submitted to CLV; and  a MCFD Request to Pay or Amend form(s) with sufficient funds allocated to CLV; and  the CLV Autism Services General Intake Form (current within the last year). Full name of child/youth: Child/youth’s date of birth: Full name of parent/guardian:
Mailing address: Phone number(s): BC CareCard number:  For new families: Please add my email address to CLV Autism Services’ email distribution list: ___________________________________________ Please check () the Social Group for which you would like to register your child. Note: while our fees may appear high at first glance, bear in mind that our hourly rates remain at $30. There has been no increase in our programs’ fees for many years; we have simply changed our Social Group registration system to align with the school year for the convenience of families, in an effort to reduce time and paperwork. Group name/location Sidney Group Meets at: St. Paul’s United Church 
S‐1516‐170
2410 Malaview Ave. Cedar Hill Group Meets at: Varies CH‐1516‐167
Life: For Realz Group Meeting at: Varies 
LFR‐1516‐168
Tillicum Group Meets at: Pearkes Rec Centre T‐1516‐169
Day/time Dates Fee* Mondays 3:30 to 5:30 p.m. not May 23 Wednesdays 4 to 6 p.m. 4 Apr to 13 Jun 10 wks 6 Jan to 15 Jun 22 wks 6 Jan to 15 Jun 22 wks 8 Jan to 17 Jun 22 wks $600 ($30/hr) $1320 ($30/hr) $1320 ($30/hr) $1320 ($30/hr) Wednesdays 7 to 9 p.m. Fridays 3:30 to 5:30 p.m. Please indicate here whether or not you require CLV transportation to or from Groups, with an address:  CLV transportation is not required, or  Please PICK UP before Group  Please DROP OFF after Group Location:  same as mailing address or this address: Location:  same as mailing address or this address: Page 1 of 3 V7 Group descriptions: Life: For Realz Our aim in this Group is to help teens take the big steps towards independence. Teens will learn life skills, develop communication skills and explore positive approaches to the being in community as young adults. The experienced Behaviour Interventionists that lead this group will mix together fun activities with skill‐
building opportunities suited to the interests of the participants. Sidney, Cedar Hill and Tillicum Groups Fun, friendship and social interaction are the focus of these groups, based at a venue or out in the community. Notes: Holidays: There will be no sessions from Monday, March 14 to Friday, March 25, 2016, inclusive, for March Break. The Sidney Group will not meet on Monday May 23 (Victoria Day).
M Minimum numbers: Social Groups may be cancelled if enrollment is too low (Groups require a minimum of 3 participants), or if no facilitator is available. Dates, locations, times, and fees are subject to change. *Pickup and Dropoff: Fees do not include the optional transportation fee of $1.00 per kilometer driven M between the pickup location and the Social Group meeting point. Travel during Social Group sessions is included in the social group fee. By signing below, I recognize and acknowledge that: 
CLV Social Group workers are Behaviour Interventionists, and, as contractors of CLV, they are coordinated by CLV. I am aware that each CLV Behaviour Interventionist has had a recent criminal record check and a thorough reference check. I have received information on the role of CLV contractors, my rights as a client of CLV and CLV’s Positive Behaviour Support Practices policy. 
I have documented any behaviours of my child that may create risk of harm to my child or others on the Autism Services General Intake Form. I acknowledge that CLV has the right to stop providing service at any time if it determines that the service is not appropriate for the child, or presents a threat of harm to the child or others. 
I understand that these fees are refundable in full until seven (7) days before the first scheduled social group session. 
Credit is not given for sessions missed due to illness or any other reason. Charges will begin on the first scheduled day of Group unless the family, the CLV office, and BI staff agree on a later start date. 
I understand that I may withdraw from a Group at any time, as long as I give a minimum of two weeks’ notice. I acknowledge that I am responsible for all applicable fees from the start of Group until the end of the second week. 
If CLV cancels the service, I will be credited or refunded for the pro‐rated value of the services cancelled by CLV. I confirm that the dates and funds in this contract are (please check one):  already covered by an existing MCFD billing number for the services identified above; or  accompanied by a new Request to Pay form (or forms) covering the services identified above; or  accompanied by a Request to Amend form (CF0925A) to cover the services identified above; or  accompanied by a cheque or money order for payment in full, or credit card authorization (call us for the form) I understand that registration will only be confirmed once CLV has been allocated sufficient funding for this service, through one of the methods above. mm m m__________________________________ Signature of Parent or Guardian _______________________________ Date Page 2 of 3 V7 PLEASE NOTE: For registration to be confirmed, the following items must be complete:  A CLV Autism Services General Intake Form has been completed and submitted within the last year; and  This registration form has been completed, including transportation; and  Sufficient Autism funds have been allocated to CLV for the duration of the group or a cheque has been included. Contact us if you wish to pay by credit card. Youth Voice Attention Groupers: At CLV, we value our participants’ input, so we want to know what activities YOU would enjoy, to make your time with CLV Autism Services as fun as possible. Please let us know what activities you would be interested in doing: 

 Music (singing, playing, listening, creating)  Adventure or extreme sports  Arts and/or Crafts  Fitness or working out in a gym  Community involvement and events  Computers and Technology (not gaming)  Dance  Socializing in small groups  Indoor Recreation  Teen Centres  Outdoor Recreation and Nature  Yoga, meditation and wellness  Swimming  Volunteering or employment skills  Cooking and baking  Boating (canoeing/kayaking)  Biking  Archery  Lego  Geo‐caching  Building  Rock‐climbing  Ceramics  Mini‐golf  Sewing  Watching movies  Animals, birds and insects  Trampolining  Gymnastics  Bowling  Fashion, hair and makeup  Rollerblading or skateboarding  Laser tag  Automotive / Car shows  Other: ______________________  Other: ______________________  Other: ______________________ M For more information on Social Groups, please contact: Jeannie Owens‐Wallace, Program Coordinator Office: (250) 477‐7231 ext. 237 Cell: (250) 686‐2892 [email protected] Page 3 of 3 V7