Four Winds Summer Program Registration Form 2023

2023 Wild Time

Summer Program Registration Four Winds Learning Community
Thank you for registering for our summer program. Please read the following form carefully as it outlines our policies. Once we approve your application, you will receive a welcome pack with more details.
- We prioritize health and wellbeing, we reserve the right to send any child home if they are unwell.
- No food or drinks will be provided. Children should bring their own water bottles, snacks and lunches.
- All children should bring appropriate outdoor gear, sunscreen and natural tick spray. We are an organic farm so please ensure these are safe and natural.
- All shared facilities will be sanitized regularly: i.e. bathrooms cleaned after each use. We will have hand sanitizer in case anyone does not have their own.
Family Information
Please tell us a little bit about your family and why you are interested in our program
How many children will be coming?

1 child2 children3 childrenOther
Child's Name

First NameLast Name
Child's Details:*
2nd Child's Name

First NameLast Name
2nd Child's Details:*
3rd Child's Name

First NameLast Name
3rd Child's Details:*
4th Child's Name

First NameLast Name
4th Child's Details:*
What week or weeks would you like your child/ren to join us?

July 3-7July 31- August 4
Tuition Fees are offered at a sliding scale. Choose according to your income level.

Full Income- 1 Child - $400Full Income - 2 Children - $725Mid Income - 1 Child - $375Mid Income - 2 Children - $675Low Income - 1 Child - $350Low Income - 2 Children - $625More than 2 children - Multiple child discountOther
Parent/Guardian Information
Primary Parent/Guardian's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
example@example.com
Parent/Guardian's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number

Area CodePhone Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does your child/ren have any allergies, chronic illness, or medical conditions? If yes, please describe.
Will your child/ren need any medications during their time at camp ? If yes, please explain any instructions.
Have we met your child/ren before? If not let's arrange a time to meet, so we know it's a good fit for your family and ours.

yes, we've been to Four Winds before.no, we just found you and would love to be introduced.
Our Updated Health Policy

At Four Winds Learning Community, we prioritize health and safety above all. Below you will find our health policy and procedures, which follow state and local guidelines for the well-being of our community.

Please print this checklist and refer to it daily before bringing your child to Four Winds. Check that your child does not have any of the following symptoms:

● Fever (100.0 Fahrenheit or higher), chills or shaking chills

● Cough (not due to other known cause, such as a chronic cough or allergies)

● Difficulty breathing or shortness of breath

● New loss of taste or smell

● Sore throat

● Muscle aches or body aches

● Nausea, vomiting or diarrhea

● Headache (when in combination with other symptoms)

● Fatigue (when in combination with other symptoms)

● Nasal congestion

● Runny nose, in combination with one other symptom, including fatigue, lethargy, irritability, lack of appetite.

If your child has any of the symptoms above, keep them home, notify us at Four Winds (413-329-5970) and contact your primary care physician.

If in doubt, please keep your child home and let us know. Any child who presents with new symptoms of illness will immediately be sent home. We would prefer not to have to turn a student away.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Four Winds LLC during the selected camp. In exchange for the acceptance of said child’s candidacy by Four Winds LLC ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Four Winds LLC . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Four Winds LLC . including all faculty and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports or play activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
In case of injury, my child may be treated with: (check all that apply)
List of traditional first aid options: (Check all that apply)
Medical Release and Authorization

As Parent and/or Guardian of the named child/ren, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Four Winds LLC. and its affiliates including Directors, Faculty, and Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Photo Release : Do you give permission for Four Winds to use photographs/videos of my child/ren for any legal use, including but not limited to: publicity, advertising, fundraising, social media, grant applications and web content?

Yes, I give permissionNo, I do not give permission
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature
Please tell us how you heard about our program?
Is there anything else you'd like us to know?
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2023 Wild Time