InnerActive Learning Consultants - Enrollment Form
Email address *
Parent / Guardian Legal Name *
Relationship to Child *
Home Address *
Contact Number *
Email Address *
Client Information
Child's Name *
Birthdate *
Allergies *
Is there any additional information or any concerns that you feel we should be aware of to best meet the needs of your child? *
Persons designated by parent to whom child may be released *
Emergency Contact Information
Emergency Contact Name / Relationship *
Emergency Contact Number *
Physician's Name *
Physician Contact Number *
Name of Insurance Provider *
Policy Number *
*Emergency Authorization *
State law requires that we have written authorization from a child's legal guardian to seek medical help in the event of a medical emergency. Selecting the box below will provide us with that authorization. Our policy, in the event of a medical emergency is to contact you first. If we can not reach you, we will try to contact any others you may designate. In the event that we are unable to contact you or your designated representative(s), or if the medical emergency warrants immediate response, we will act on behalf and in the best interest of the child.
Photo / Image Release *
InnerActive Learning Consultants, LLC may wish to use pictures/images of your child participating in our service. By selecting the Image Release, you are granting permission for your child's image to be used in relation to InnerActive's promotional items, website, social media information, and other service related material.
A copy of your responses will be emailed to the address you provided.
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