REGISTRATION FORM

Start Date: ________________________ Program Name: __________________________
Name of Child: _____________________ Birth Date ____/____/____ Pronoun: _______

Who are you affiliated with: _________________________ Age: ___________________
Care Card Number: ___________________________ Phone: __________________

Medical Practitioner Name: _______________________ Address: _______________________

PLEASE NOTIFY US WHEN YOU CHANGE ADDRESSES, PHONE, OR WORKPLACE

BELOW, CONTACT INFORMATION OF 2 ADULTS WHO WILL BE FIRST AND SECOND CONTACTS

Name: _____________________________ Address: ___________________________ Home Number: ______________________ Work Number: ______________________ Cell Number: _______________________ Place of Work: ______________________	Name: _____________________________ Address: ___________________________ Home Number: ______________________ Work Number: ______________________ Cell Number: _______________________ Place of Work: ______________________

PERSON/S AUTHORIZED TO PICK UP OR DROP OFF YOUR CHILD AND EMERGENCY CONTACTS

1. NAME:________________________________PHONE #:__________________________

2. NAME:________________________________PHONE #:__________________________

3. NAME:________________________________PHONE #:__________________________

Has your child experienced Nature-based or Performing Arts before?

What kinds of activities are you hoping your child will experience?

Do you want to participate in activities with your child?

Do you have interest in participating in fundraisers to enhance programming?

PERSON/S UN-AUTHORIZED TO PICK UP OR DROP OFF YOUR CHILD

1. NAME:________________________________PHONE #:__________________________

2. NAME:________________________________PHONE #:__________________________

Please provide special instructions below concerning behavior, medication or diet.

Behavior:

________________________________________________________________________________________________________________________________________________________________________

Strategies:

________________________________________________________________________________________________________________________________________________________________________

Medication:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diet:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Commitment of Service

Heightened awareness while in the Wilderness, on Adventure and during Social Engagements

Safe transportation to and from activities

Be on time and be prepared for activities

Duty of care to take reasonability to avoid harm of self and children

Diligent care when dealing with inherent and unforeseen risks

Client confidentiality

Provide service rain or shine

Give at least 2 weeks notice to change scheduled time, unless un-foreseen circumstances

Inform you if we feel that your child’s needs are something that we can or cannot manage

Following Covid Protocol

Commitment to Provider

My signature below indicates that I have reviewed the website, and understand what I am signing my child up for, and understand the services offered by the Director and staff

My signature below authorizes our Director or staff, to obtain a Physician and/or Ambulance in the event of an emergency.

I also hereby understand that the Director or staff, to the best of their ability, will keep our child’s possessions safe, and yet if the child’s possessions are misplaced, they is not responsible for replacing them.

In consideration of the child’s needs, I/we acknowledge and agree that he/she may be transported in and use any facilities the Director or staff deems fit for Intervention. We understand that any violent interaction between the child and any staff at the Wild Craft Play ‘sCool and/or parent and Director or staff, could compromise the contract, and may be terminated due to said cause.

In the case of an accident where the Director or staff, and any affiliate has provided due diligence, they will not be held liable.

I also hereby understand and agree that my family’s personal information collected on this document for the sole use of the Director or staff, and it is for the purpose of the delivery of safe and enjoyable child care.

I, ____________________________________have read and agree with the following terms and information. If I have any questions regarding this information I will speak to the Director or staff before initialing and signing off on this contract.

Please initial each section upon reading. By doing this you are stating that you understand and agree with each procedure listed.

GENERAL INFORMATION

_____ * One month’s written notice is required to cancel. This must be in writing (preferably by email) and given to Director or staff. I acknowledge if I give less than one month’s notice, I am required to pay for one month after notice is given.

_____ * In the event of absenteeism due to illness, vacation, etc., not initiated by Director or staff, I understand I am still responsible for full payment of service.

Print Parent/Guardian Name: _____________________

Parent/Guardian Signature: _______________________ Date: _______________________

Program Manager Signature: _______________________ Date: _______________________

Parental Permission for Outings and Media Release,

Within the services at Wild Craft Play ‘sCool, at times we require permission from parents and guardians for things such as outings, permission to take photographs of children for the newspapers or our website, or even for permission to apply sunscreen on your child. Please fill in the form below indicating whether or not you would like your child to take part.

I, ____________________________________________, being the parent/guardian for

___________________________________________, hereby advise the Director of the following:

• I permit the Wild Craft Play ‘sCool Director and staff (WCP’sC) to take my child/ren on day outings throughout Vancouver Island. Yes No

• I permit the WCP’SC to apply sunscreen on my child/ren as requested by parent. Yes No

• I permit the WCP’SC to photograph my child/ren for display in social media online. Yes No

• I permit the WCP’SC to photograph or film my child/ren for the creation of a documentary or video for RESEARCH purposes ONLY. Yes No

• I permit the WCP’SC to photograph or film my child/ren for the creation of a documentary or video for MARKETING purposes ONLY. Yes No

• I permit the WCP’SC to transport my child in a licensed vehicle when informed. Yes No

I also understand that by my signature below, I agree to indemnify and save harmless the Wild Craft Play ‘sCool Director and staff from and against any and all claims or liability issues that may arise.

Print Parent/Guardian Name: _____________________

Parent/Guardian Signature: _______________________ Date: _______________________

Program Manager Signature: _______________________ Date: _______________________

POSSIBLE OUTDOOR ACTIVITIES & SAFETY INFORMATION

Our goal is for everyone to have fun! The types of outings that we can offer at this camp are the dark printed items:

Swimming with PFD Kayaking with PFD Canoeing with PFD Caving	Hiking Mountain Biking Archery Wilderness Survival Training	X Country Skiing Sword Play Imaginative Play & Quests Wild Crafting

One way to be safe is to have our safety rules. Whenever swimming, riding a bike, paddling, hiking or exploring, the child must practice safe actions and manage risk, or else the Director or staff will cancel the activity and the child will be taken home. All safety devices must be worn properly, and my child recognizes that they only work when used properly. It must be fitted properly to the child according to safety regulations.

I understand the Wild Craft Play ‘sCool will not provide safety equipment, survival kit, cell phone and extra first aid equipment kept in vehicle.

HIKING LEVEL & SURVIVAL INFORMATION

CHECK ANY/ALL:

… Local Parks

Any park across Vancouver Island

… Back country

… Allowed to walk bare-foot

Initial: ____ * I understand that my child requires a survival kit, which I will supply.

MOUNTAIN BIKING LEVEL & SURVIVAL INFORMATION

CHECK ANY/ALL:

… Local Parks

Any park across Vancouver Island

… Back country trails

… on the road

Initial: ____ * I understand that my child requires a functioning bike and helmet if required.

ARCHERY LEVEL & SURVIVAL INFORMATION

CHECK ANY/ALL:

… permitted to use archery equipment in permitted areas

… needs training

… NOT permitted to use archery equipment at all

Initial: ____ * I understand that my child requires to wear long sleaved shirt, gloves, and pay attention.

SWORD PLAY & SURVIVAL INFORMATION

CHECK ANY/ALL:

… permitted to use foam swords in permitted areas

… needs training

… NOT permitted to use foam swords at all

Initial: ____ * I understand that my child requires to wear closed toed shoes, & must listen to instruction.

IMMUNIZATION RECORD

Name of Child: __________________

Please fill out Emergency Card information in the cards below. Then,

please print and provide a 4 x 6 photo of your child’s face.

INFORMED CONSENT

(please initial in the spaces below)

_____ I confirm to the best of my knowledge that my child does not suffer from any medical condition other than those listed above.

_____ I understand that if my child shows any signs of Covid symptoms, I am required to inform staff immediately, discontinue attending the program and get tested.

_____ I understand that if my child tests positive for Covid 19, I am to inform staff immediately and the program will be shut down until further notice.

_____ In the event that my child requires emergency medical attention, I consent to my child being transported to the nearest emergency centre, including by ambulance if necessary, and accept that I am responsible for any costs of such ambulance service.

COVID-19 DECLARATION

Based on having read and understood the foregoing, I declare as follows:

By participating in your programs and/or visiting your facilities, I will be at risk of contracting Covid-19, in spite of any precautions taken by me or by facility/program staff. Covid-19 is a highly infectious disease with a latent period of transmissibility during which time apparently healthy people can be infectious. Covid-19 is a potentially fatal disease affecting people of all ages. Covid-19 can be significantly more dangerous in people of already compromised health, and it is my responsibility – not that of program or facility staff – to understand my current health and limitations and to take appropriate additional precautions as required.

I understand that if infected, I could be at risk of transmitting the disease to other family members, including those with high risk, pre-existing conditions, and that this might occur before my own sickness has become evident.

I have read and understand the above information and willingly accept the above risks.

________________________ __________________________ ______________ Signature of Parent or Guardian Name of Parent or Guardian (please print) Date