Holistic Learning Academy Registration Form- 2024 -2025
Thank you for planning to attend our Academy. Please complete the following form in its entirety. 

A $75.00 registration fee must be made upon completion of this form via Zelle: HOLISTIC LEARNING ACADEMY LLC, or CASHAPP: $Holisticlearning 

Please contact us at 561-723-1668 if you have any questions or concerns. Please allow 24 hours for us to return your call. 



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Child's First & Last Name  *
Child's Date of Birth *
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Child's Height, Weight, Hair color, Eye color  *
Child's School & Grade  *
Child's Current Age  *
Legal Custody (If there are any custody agreements, documents must be on file with HLA) *
Parent/ Guardian Information
Please provide your name, phone number, address, & e-mail address.
Parent/ Guardian 1 ( Name, Address, Phone #, & E-mail) *
Parent/ Guardian 2 (Name, Address, Phone #, & E-mail, if different from above) *
Emergency Contacts/ Pick-Up Authorization
Please list, in order authorized persons, other than the parent/guardian to contact in case of emergency.
Please list up to five authorized persons for emergency/pick-up. Please include their name, number, and relationship to the child. *
Medical Information (Please read) 
Medication Release Form is required to administer medication. Children may not medicate themselves.    

Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. 

You or your emergency contact need to be available to pick up your child from school in the event of a medical emergency you will be notified immediately. These include: Student illness or Severe injury

You will be notified in the event of any injury if so requested on the Contact and Health Form.

We have First Aid and CPR-trained staff members, who will take whatever emergency medical measures are deemed necessary for the protection and safety of your child. This may include transportation by ambulance to the nearest medical treatment facility.

MEDICATION

If your child has special needs for medication during the day, please make those needs clear on your Health Form.

Children are expected to bring whatever medical supplies or medications they will need each day and turn it in to staff, along with written instructions. Staff will be happy to remind them to take medication if we are notified in writing about their schedule. If your child has a strong allergy to bee stings or other conditions that require the use of an epi-pen, the child is expected to have the required supplies with them at all times, and also they should know how to administer these injections themselves.

COMMUNICABLE DISEASES 

Campers, including their siblings with an infectious illness (H1N1, pink eye, hand, foot & mouth disease, etc.) must be removed from camp immediately for the safety of the other campers.

Please provide any medical information for your child. (allergies, medical conditions/treatments) *
Please provide Primary Doctors Name, & Phone Number  *
Please provide Insurance provider, Policy Holders Name, & Policy Number:  Please also include a copy of the front and back of your insurance card to the office staff.
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Does your student have any limiting medical conditions that you or your doctor feel would limit students' participation?

Yes, or no? If yes, please explain.
*
NOTIFICATION: Do you want to be notified immediately during the school day for minor injuries (e.g.: scrape, non-allergic bee sting, bloody nose, sliver) that do not limit participation in the program?
*

SPECIAL NEEDS: Are there any physical, mental, psychological or behavioral conditions requiring medication, treatment, or special restrictions or considerations while at camp of which we should be aware to ensure your child’s fullest enjoyment of their camp experience? Please describe, including any special accommodation necessary. Please note that it is your responsibility to supply any necessary medical equipment which relates to a specific medical condition. Are there any activities from which the student should be exempted for health reasons?  

Please let us know when you register if your child is physically challenged or requires some type of special assistance. You can contact Mrs. Hall (561) 723-1668. 

Yes, or no? If yes, please explain.

*
What is something that you would like us to know about your child? *
PARENTAL CONSENT 
 
 I, parent/guardian of the participant, agree with the following statements:    

1. I understand that I am responsible for submitting the reimbursement through STEP UP for students on the first of each month. Payment is due at time of registration.

2. I give consent for my child to be escorted by HLA staff to nearby park. 

3. I understand that HLA will not assume responsibility for any injury incurred while participating in athletic events, childcare programs, parent/child event and outings, special events, sports programs, or any related sponsored activities. Certain risks of injury are inherent during participation in these programs and events. Nor will HLA be responsible for any lost or stolen items while members and/or program participants are using the facility or on off-site program locations. I, the undersigned for myself and my heirs, do hereby release HLA and its employees and agents from any and all claims for injury, loss, or damage I may suffer as a result of my participation. This includes any injury caused by negligence, if any, its officers, employees, agents, volunteers, or the negligence of anyone else.

4. PERMISSION TO SECURE TREATMENT 

In the event of any emergency, I authorize HOLISTIC Learning Academy Staff to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my minor child/ward’s immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility or hospital if I am unable to be reached first. RELEASE OF LIABILITY AND PERMISSION TO SECURE TREATMENT I recognize and acknowledge that there are certain risks of physical injury to participants in the above program(s) and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program(s). I agree to waive and relinquish all claims I or my minor child/ward may have against HOLISTIC Learning Academy and its officers, agents, volunteers and employees as a result of participation in the program. I do hereby fully release and discharge HOLISTIC Learning Academy, and its officers, agents, volunteers and employees from any and all claims from injury, damage or loss with the activities of the program(s). I further agree to indemnify and hold harmless HOLISTIC Learning Academy and its officers, agents, servants and employees from any and all claims resulting from injuries, damages, and losses sustained by me or my minor child arising out of, connected with, or in any way associated with the activities of the program(s). 

 *
PARENTAL CONSENT 
 
 I, parent/guardian of the participant, agree with the following statements:    
PHOTOGRAPHY RELEASE As a parent or legal guardian of the registered student at HOLISTIC Learning Academy, I understand and consent to the use of my child’s photograph on HOLISTIC Learning Academy Intranet and Internet Site, for or in any official HOLISTIC Learning Academy, l publication, and for any official HOLISTIC Learning Academy, undertaking. I have read and fully understand the above Release of Liability and Permission to Secure Treatment and Photography Release. 
 *
Parental Consent 

Late-pickup: A late fee of $25.00. 

CODE OF CONDUCT

Students are expected to display appropriate behavior at all times. To assure the maximum enjoyment of the program by all participants, please review the following guidelines with your child. Your child is expected to: 

Show respect to all participants, staff, and nature. Use equipment, supplies, and facilities properly. Be pleasant to others and refrain from using foul language. Refrain from causing harm to self, other participants, and staff. Always wear shoes. Stay with the group.

DISCIPLINE

If behavior problems arise, you will be contacted that day to discuss the nature of the problem. The following disciplinary techniques will be used for uncooperative children:

1. Verbal Warning

2. Time out: the child is removed from the activity (but not from the vicinity) for duration of up to one minute for each year of age.

3. Parent involvement: if the child has difficulty controlling themselves, the parent will be contacted  to handle the situation.

4. The Director may immediately suspend a child at any time should the child’s behavior become extremely harmful to the staff, children, or him/herself.

5. Removal from program: if problems persist or the behavior is severe such as causing intentional harm to others or consistent disruptions of camp activities, the child will be removed from the program.
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Please print your first and last name indicating you have read and understand the information provided.  *
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