GL Application Form

I understand that Sandbox Clinic is a CHED-recognized Clinical Training Institution and that the Sandbox Internship Program (SIP) is conducted in partnership with its affiliated universities: University of Santo Tomas, De La Salle Medical and Health Sciences Institute, and Far Eastern University.

As part of this program, therapy sessions may be conducted by Clinical Interns/Student Therapists who are completing their supervised practicum requirements and are being trained to become licensed professionals. All sessions will be carried out under the close supervision and guidance of Sandbox Clinic's Licensed Clinical Supervisors and Instructors, who remain responsible for ensuring the quality and safety of care.

By enrolling my child under the SIP, I acknowledge and accept that their therapy will be facilitated as part of the internship program, and I fully understand the structure, purpose, and educational nature of this arrangement.

This is to certify that our role in relation to the Office of the President Guarantee Letter (GL) application is solely as the provider of services and the source of the required supporting documents, such as service quotation and the Certificate of Guarantee Letter Acceptance.

The review, evaluation, and approval of the GL application are undertaken exclusively by the Office of the President and/or the appropriate government authority. We do not participate in, nor exercise control over, the assessment or approval process beyond the submission of the stated requirements.

Sandbox Clinic is committed to providing a safe, respectful, and supportive therapeutic environment for all children, families, and staff. We extend courtesy, professionalism, and compassion to every client and expect the same level of respect in return.

Clients and accompanying adults are expected to:

1. Treat all therapists, staff, and other families with kindness, courtesy, and respect.
2. Communicate concerns or feedback in a calm, constructive, and appropriate manner.
3. Refrain from any form of verbal abuse, harassment, intimidation, or threatening behavior.

Sandbox Clinic reserves the right to refuse, suspend, or terminate non-emergency services in cases of repeated or serious disrespectful, abusive, or unsafe behavior toward staff or other clients, in order to protect the well-being, dignity, and safety of everyone in the clinic.

I hereby give my full consent to Sandbox Clinic and its authorized representatives to collect, store, and use my personal and medical information for the purpose of evaluating and processing my application for financial assistance under the Sandbox Internship Program.

I understand that:

• The personal data collected includes, but is not limited to, my name, contact information, medical history, therapy needs, government-issued identification, and financial status.
• My data will be used strictly for purposes related to therapy program eligibility assessment, documentation, LGU coordination, and program monitoring.
• My information will be handled with strict confidentiality and in accordance with the Data Privacy Act of 2012 (R.A. 10173).
• I have the right to access, correct, and withdraw my data at any time by submitting a written request to Sandbox Clinic, with the understanding that this may affect my eligibility for assistance.
• My data may be shared with partner institutions (such as UST, La Salle, FEU, and my LGU) only for legitimate program-related purposes and under the same privacy standards.

By clicking I AGREE below, I affirm that I understand and accept the terms of this consent.