2017-18 Garden Club Registration Form
Child (Participant)
Name (first and last): *
Your answer
Grade (entering Fall 2017): *
Birthdate: *
MM
/
DD
/
YYYY
Age: *
Your answer
Street address, city, state, zip code: *
Your answer
Parent/Guardian
Name (first and last): *
Your answer
Street address, city, state, zip code: *
Your answer
Cell phone number or primary phone number: *
Your answer
Can we text your cell phone?
Secondary phone number(s) (work/home/cell):
Your answer
E-mail:
Your answer
Employer:
Your answer
Parent's location when child is in program (work, home, etc.): *
Your answer
Phone number at location: *
Your answer
Emergency Contact Person 1
Name (first and last): *
Your answer
Street address, city, state, zip code:
Your answer
Primary phone number: *
Your answer
Secondary phone number (work/home/cell):
Your answer
Relation to Child: *
Your answer
Emergency Contact Person 2
Name (first and last): *
Your answer
Street address, city, state, zip code:
Your answer
Primary phone number: *
Your answer
Secondary phone number (work/home/cell):
Your answer
Relation to Child: *
Your answer
Placement and Security
Garden Placement *
Please choose the location your child will be attending Garden Club
Security *
Will your child walk to/from the Garden Club?
Permitted adults
If your child will not be walking from Garden Club, please list people including parents/guardians who are permitted to pick up your child on the lines below.

*Note: We ask that you, or whoever is picking up your child, sign your child out each day upon pick-up. For safety and security, your child will not be permitted to leave until a designated adult has signed him or her out, unless we have been given prior permission to allow them to walk.

Permitted adult 1
Your answer
Permitted adult 2
Your answer
Permitted adult 3
Your answer
Permitted adult 4
Your answer
Demographic Information
The following information is needed for us to accurately report about our program to our federal grant funders. This information will not be shared.
Gender of child *
Race *
(check all that apply)
Required
Eligibility for Food Assistance *
Is your household eligible for the SNAP benefits (food stamps or bridge card)
Health Information Record
Health Insurance Provider
Your answer
Policy Holder Name
Your answer
Policy Number
Your answer
Physician Name
Your answer
Physician phone number
Your answer
Physician address
Your answer
Hospital preferred for Emergency Treatment *
Your answer
Health History/Condition
List any Medical Conditions your child has:
Your answer
Please check all of the following medical conditions that apply to your child
List any medications your child is currently taking
Your answer
Please list any food allergies your child has *
If your child doesn't have any food allergies, please write "None"
Your answer
Please type your full name and today's date in the box below to give permission to NWI to secure medical and/or emergency care for your child. *
I HEREBY GIVE NORTHWEST INITIATIVE (NWI) PERMISSION TO SECURE MEDICAL AND/OR EMERGENCY TREATEMENT FOR THE ABOVE NAMED MINOR WHILE IN NWI’S CARE
Your answer
Parent Release Form for Media Recordings
I, the undersigned, do hereby grant permission to the NorthWest Initiative (NWI), to use the image of my child, as marked by my selection(s) below.

Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the NWI website or Garden Club Facebook page.

Please select from the following: *
Terms of Parent Agreement
It is the sole discretion of the NorthWest Initiative to reserve the right to refuse admission to, or require withdrawal of, a camper, if necessary. NWI is not responsible for lost or damaged personal property. All scheduled events are subject to change, and I will be informed of these changes as they occur.
Behavior *
The Garden Club Coordinator reserves the right to dismiss a child due to behavior discipline problems. Inconsideration of my child participating in the NorthWest Initiative’s Garden Club, I, the undersigned agree to release and on behalf of my minor child, myself, our heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE the NorthWest Initiative, its officers, agents, employees and partner schools from any cause of action,claim, or demand of any nature whatsoever, including but not limited to, a claim of negligence, which I, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against the NorthWest Initiative on account of personal injury property damage, death or accident of any kind, arising out of or in any way related to my child’s participation in the Garden Club, supervised or unsupervised, however the injury or damage is caused,including, but not limited to the negligence of the NorthWest Initiative, its officers, agents, and employees. I further understand that the terms of this agreement are legally binding and certify that I am signing this agreement, after having carefully read it, of my own free will.
Health *
I hereby certify that my child is in good health and that she/he has no physical limitations which would preclude their participation in the Garden Club of the NorthWest Initiative.
Emergency Treatment *
I hereby give permission to the NorthWest Initiative and the emergency care person listed on this form to secure emergency medical treatment and non-emergency medical treatment for the child named on this form while in the care of NorthWest Initiative. Elective surgery is not included in this authorization.
Email *
By providing my e-mail address, I am giving permission for the NorthWest Initiative to communicate with me electronically. I understand that the NorthWest Initiative will never release my personal information, including e-mail, to any third party.
Please type your full name and today's date in the box below to show your agreement. *
Your answer
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