Registration for Earth Path Nature School Programs, Ottawa - Winter/Spring 2019

Which Ottawa program are you registering for? *
Required
How would you like to pay?
Participant's Full Name *
Your answer
Date of Birth (DD/MM/YYYY) *
Your answer
Participant's Age *
Your answer
My child's gender is...
Your answer
Languages Spoken *
Required
Mailing Address (House #, Street Name, Town, Province, Postal Code) *
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Phone Number *
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Email Address *
Your answer
Mother's or Legal Guardian's Full Name *
Your answer
Father's or Legal Guardian's Full Name *
Your answer
Adults Authorized for Pick-Up *
Please list the names of adults who are authorized to pick up your child.
Your answer
Emergency and Health Information
If a parent/guardian cannot be contacted in an emergency, please contact:
Name of Emergency Contact *
Your answer
Phone Number *
Your answer
Name of Child's Physician and Physician's Phone Number (if applicable) *
Your answer
Does your child have any allergies or dietary restrictions? If so, please specify. *
Your answer
Does your child carry/need an EpiPen and know how to use it? *
Your answer
Is your child allergic to bee or wasp stings? *
Required
Date of last immunization for tetanus *
Or N/A if never been immunized for tetanus.
Your answer
I give consent for my child to receive the following as needed (please check all that apply): *
Required
Does your child have any special needs (e.g. physical, mental, or emotional)? We would like to know how best to support your child, including how to relate to him/her. *
Your answer
Other Useful Information For Us
What do you hope your child will learn from this experience?
Your answer
What experience does your child have outdoors?
Your answer
In what learning environments does your child do best? Do you have any concerns or suggestions about his/her behavior in groups?
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For participating children/teens: What types of activities and skills that we offer are you excited to do/learn? Is there anything else you would like to tell us? 



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Informed Consent Agreement and Safety and Release Form
In order to attend an Earth Path program, our Informed Consent Agreement and our Safety and Release Form must be completed for each child. These forms can be downloaded from our website and mailed in, or they can be completed on the first day of the program. Please arrive 10 minutes early if you plan to complete the forms on the first program day. Thanks!
Cancellation Policy
If you cancel before or on December 24, we will reimburse you fully, minus the non-refundable $100 deposit. After December 24, regrettably no refunds can be issued, unless we are able to fill your child's space.
Declaration
By signing below, I declare that I am the legal guardian of the participant being registered for this program. I declare that the information supplied by me on this form is, to the best of my knowledge, true and correct. I understand and agree to the Cancellation Policy stated above.
Parent/Legal Guardian's Signature (print full name below)
Your answer
Mailing List
Would you like to subscribe to Earth Path's mailing list to receive seasonal updates on our programs/events? *
We typically send 1-2 emails per season, and you can unsubscribe at any time by emailing info@earthpath.ca with the subject line "Unsubscribe".
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