Rainbow Tree - Registration Form
If you have not sent payment or completed the payment on the website or made other arrangements with Lisa Haverly for check payment, please do so by going to the following web address: www.rainbowtreetherapies.com or you can contact Lisa at rainbowtreeinfo@gmail.com Thank you.
Email address *
Child's or Registrants First Name *
Your answer
Last Name *
Your answer
Child's Date of Birth - NOT REQUIRED FOR PARENT CAMP *
MM
/
DD
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YYYY
Emergency Contact/Liability Docs/Permission Docs
The below information will be utilized in replace of an electronic signature. By clicking the agree boxes, you will be agreeing to the liability information and permission document details. All details of the below can be viewed under the Frequently Asked Question page on the website. https://www.rainbowtreetherapies.com/pages/liability-documents
Gender
Register for the following Sessions: *
Required
Age
Your answer
First Name
Your answer
Parent/Guardian Information
Last Name
Your answer
City
Your answer
Address
Your answer
State
Your answer
Zip Code
Your answer
Primary Contact/Phone Number
Your answer
Secondary Contact
Your answer
Email Address
Your answer
Emergency Phone
Your answer
Name of Emergency Contact
Your answer
RELEASE OF LIABILITY *
Please review details of liability by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents
Required
PHOTO RELEASE *
Please review details of photo release by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents
CHALLENGING BEHAVIOR PLAN
CONSENT FOR MEDICAL TREATMENT *
Please review details of medical treatment form by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents
If you checked I do NOT give consent to medical treatment, please provided a brief explanation for wishes for medical treatment.
Your answer
Therapeutic Riding and Animal Assisted Therapy Release *
Required
Physical and/or Dietary Restrictions
PLEASE DESCRIBE.
Your answer
Allergies
Please describe and treatment protocol.
Your answer
Medications
Your answer
Has your child ever had a seizure? Have you as a parent camper ever had a seizure?
Areas of special need or significant medical condition?
Your answer
“I understand that Rainbow Tree Therapies, LLC will maintain my privacy to the highest standards. I understand that personal information will not be shared with anyone not affiliated with Rainbow Tree Therapies, LLC. I understand that personal information received through this registration will only be shared with professional staff at Rainbow Tree to ensure the safety my child and to ensure my child receives appropriate support needed while at camp." *
Does your child have an IEP, receive OT, PT or Speech or have any other specialized support?
Please describe your child's special interests and talents as well as any challenges your child is managing. Thank you!
Your answer
Comments or Questions?
Your answer
Do you wish to be added to the mailing list to be updated on future events?
***Your email address will not be used for any purpose other than to provide you with information. At any time, you can be removed from the mailing list.
Do you wish to be added to a carpool document? By saying yes, you would be agreeing to having first name, email address and the town in which you live added to a list. The list would be sent to families who have inquired about carpooling. This does not guarantee a carpool for transportation. *
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