WILD CHILD 2018-19 Registration
Email address *
I am registering for: *
Child's Name *
Your answer
Birthdate *
MM
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DD
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YYYY
Additional Child's Name
Your answer
Additional Child's Birthdate
Your answer
Parent Name(s) *
Your answer
Address
Your answer
Home Phone *
Your answer
Cell Phone
Your answer
Additional Emergency Contact Name and Phone Number *
Your answer
Physician Name and Phone Number
Your answer
MEDIA RELEASE: I hereby grant free permission for Wisdom of the Earth Wilderness School to use images of my child and myself participating in their programs or events for outreach purposes, including but not limited to photo, audio, and / or video media. Please consider granting this release to us if at all possible, as our ability to successfully share our programs with new participants depends on having representative media. *
Do you or your child(ren) have asthma and/or any serious allergies to any insects, plants, foods, medications, etc ? If so, does s/he have medication or carry an epi-pen? (please explain) *
Your answer
Do you or your child(ren) have any physical conditions that may limit or impact participation in this program? If so, please describe, including any medications we should be aware of: *
Your answer
Any mental, emotional, psychological or family issues we should be aware of? All information is kept confidential (may be shared with relevant staff) and is meant to provide a supportive and safe atmosphere for all involved in the program. *
Your answer
In the event of an emergency situation where family members cannot be contacted, do you authorize Wisdom of the Earth staff to obtain, through a physician of their choice, medical care that may become reasonably necessary? *
Additional comments or notes to Wisdom of the Earth staff:
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