Course Registration Form

Child’s Name

First NameMiddle NameLast Name

Child’s Birth Date

MonthDayYear

Child’s preferred pronouns

Child’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies/Medical Condition(s)

My child is currently taking these medications:

Child’s Doctor Name

Parent/Guardian Name

Parent/Guardian E-mail

example@example.com

Mobile Number

Work Number

Parent/Guardian Name

Parent/Guardian E-mail

example@example.com

Cell Phone Number

Work Phone Number

Name two local emergency contacts who are authorized to pick up your child. Please provide Name(s) and Phone Number.

I give permission for Hearty Girl Staff to administer the following medications to my child:

Sunscreen (Babyganics SPF 50+)Natural, DEET (-free bug spray)South Sting Swabs in case of stingsBaby wipes in case of toilet accidents

Authorization to Act in the Event of Minor Injury. In the event of a minor injury, such as a scrape or small cut, I authorize the staff of Hearty Girl to administer first aid for my child. Parent/Guardian Initials:

Permission to Transport in an Emergency. I give permission for my child to be transported in the case of an emergency, such as an evacuation. Parent/Guardian Initials:

Authorization to Act in an Emergency. In the event of a medical emergency, I authorize medical personnel to care for my child and/or transport my child to the hospital. I authorize the administration of emergency medical treatment to my child by a qualified practitioner in my absence. Parent/Guardian Initials:

Animal and Pet Permission. I understand that my child may be exposed to wild animals while playing outdoors. Parent/Guardian Initials:

Photo Permission. I understand that my child’s photo will be included in the daily email seen only by families in our program. Parent/Guardian Initials:

Walking Field Trip Permission. I understand that my child will participate in daily walking field trips on the grounds of Duluth City Parks while enrolled in Hearty Girl for the purpose of nature play and study. Parent/Guardian Initials:

Enrollment: My child will attend the following days:

MondayTuesdayWednesdayThursday

Months I would like my child to attend:

JuneJulyAugustOther

Are there any days or weeks that you know of in advance that your child will not be attending Hearty Girl?

I am indicating that I agree to the days of enrollment. I understand that I am responsible for payment of contracted fees for Hearty Girl. Parent/Guardian Initials:

If possible I would like my child placed with (specify name of child/children)

How do you prefer to receive communication?

EmailPhoneMailIn Person

How would you prefer to pay for Hearty Girl?

CheckCashVenmoPayPal

Please tell me about your families traditions and customs.

What are your child’s special interests?

Is there any other information you would like to share with me about your child and/or your family at this time?

I have read and understand the information in this form. I have indicated my consent and authorization where applicable.

Parent/Guardian Signature

Parent/Guardian Name

Please contact Hearty Girl Director Alyssa Nelson at nelsonmalyssa@gmail.com or 507-990-3708 with any questions or concerns.

Child Information