Rosebud Program Fall to Winter 2020 Registration Form

Wild Rose Farm Rosebud Program

Fall to Winter Session: November 9 - December 14, 2020
Child's Name *

First Name Last Name
Birthdate *
Parent/Guardian 1 *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Additional Phone

Area Code Phone Number
Parent/Guardian 2

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Additional Phone

Area Code Phone Number
Main Contact: *

Parent/Guardian 1 Parent/Guardian 2 Please contact both
EMERGENCY CONTACT & CARE INFORMATION
Emergency Contact: *

First Name Last Name
Contact Phone: *

Area Code Phone Number
Relationship *
Emergency Contact 2: *

First Name Last Name
Contact Phone: *

Area Code Phone Number
Relationship to child: *
Name of child's Primary Care Physician *

First Name Last Name
Preferred Medical Facility *
Insurance under which child is covered *
ID Number *
Group Number *
Subscriber *

First Name Last Name
Does your child have any special dietary needs or restrictions? *
Does you child experience any allergies (foods, medications, insect stings or environmental)? *
Is your child taking any regular medications? *
Is these anything else you'd like to share about your child? *
Registration & Payment
Program Fee Payment Options

Please contact me as I'd like to set-up a payment plan or discuss financial support

Registration Payment

Registration Fee $ 25.00

non-refundable

Program Supplies Fee $ 25.00

non-refundable

Program Fee for 6 Monday's $ 180.00

one time, payment in full

Program Fee for 6 Monday's $ 90.00

1/2 payment, balance due by December 7th

Total $ 0.00

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