CRHC: Garden Class Registration Form

Did you know that kids who garden eat more fruits and veggies?

Clarinda Regional Health Center is excited to enter a new phase of the well-loved All-Star Sprouts Garden Program in a newly renovated garden! CRHC's kids garden program is located on the NW corner of campus and will be held every Thursday in June for kids ages 4-9 years old. This program is run by CRHC's Registered Dietitians, who teach your children about planting, harvesting, and cooking with the produce we've grown together in our garden throughout the summer.

Summer 2025 Class Schedule:
Session 1: Thursdays from 8:15 -9:00am (Class Full)
Session 2: Thursdays from 9:15 - 10:00am

There are 25 spots available for each session and no cost to register your child! Just fill out the form below.

How many children are you signing up today?*

Child's Name*

First NameLast Name

Which session do you want your child to attend?*

Age*

XS (4-6)Small (6-8)Medium (10-12)Large (14-16)

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone numberFormat: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Does your child have allergies that we need to know about?*

YesNo

By marking yes and signing below, I grant permission for my child(ren) to be photographed and/or recorded while participating in Clarinda Regional Health Center’s Garden Program. I understand that this content may be used in promotional materials, shared on social media, or other communications to highlight the program/healthy eating initiatives for CRHC. I also acknowledge that in certain situations, such as group/crowd shots, my child’s image may appear unintentionally to third parties (other parents). If I do not wish for my child to be photographed, I'll indicate this by selecting "no" on this form, and I will also agree to complete a declined Photo Consent form upon dropping off my child(ren) on the first day of class.

YesNo

Signature*

DateTime*

Child's Name #2*

First NameLast Name

Which session do you want your child to attend?*

Age*

XS (4-6)Small (6-8)Medium (10-12)Large (14-16)

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone numberFormat: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Does your child have allergies that we need to know about?*

YesNo

By marking yes and signing below, I grant permission for my child(ren) to be photographed and/or recorded while participating in Clarinda Regional Health Center’s Garden Program. I understand that this content may be used in promotional materials, shared on social media, or other communications to highlight the program/healthy eating initiatives for CRHC. I also acknowledge that in certain situations, such as group/crowd shots, my child’s image may appear unintentionally to third parties (other parents). If I do not wish for my child to be photographed, I'll indicate this by selecting "no" on this form, and I will also agree to complete a declined Photo Consent form upon dropping off my child(ren) on the first day of class.

YesNo

Signature*

DateTime*

Child's Name #3*

First NameLast Name

Which session do you want your child to attend?*

Age*

XS (4-6)Small (6-8)Medium (10-12)Large (14-16)

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone numberFormat: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Does your child have allergies that we need to know about?*

YesNo

By marking yes and signing below, I grant permission for my child(ren) to be photographed and/or recorded while participating in Clarinda Regional Health Center’s Garden Program. I understand that this content may be used in promotional materials, shared on social media, or other communications to highlight the program/healthy eating initiatives for CRHC. I also acknowledge that in certain situations, such as group/crowd shots, my child’s image may appear unintentionally to third parties (other parents). If I do not wish for my child to be photographed, I'll indicate this by selecting "no" on this form, and I will also agree to complete a declined Photo Consent form upon dropping off my child(ren) on the first day of class.

YesNo

Signature*

DateTime*

Child's Name #4*

First NameLast Name

Which session do you want your child to attend?*

Age*

XS (4-6)Small (6-8)Medium (10-12)Large (14-16)

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone numberFormat: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Does your child have allergies that we need to know about?*

YesNo

By marking yes and signing below, I grant permission for my child(ren) to be photographed and/or recorded while participating in Clarinda Regional Health Center’s Garden Program. I understand that this content may be used in promotional materials, shared on social media, or other communications to highlight the program/healthy eating initiatives for CRHC. I also acknowledge that in certain situations, such as group/crowd shots, my child’s image may appear unintentionally to third parties (other parents). If I do not wish for my child to be photographed, I'll indicate this by selecting "no" on this form, and I will also agree to complete a declined Photo Consent form upon dropping off my child(ren) on the first day of class.

YesNo

Signature*

DateTime*

Child's Name #5*

First NameLast Name

Which session do you want your child to attend?*

Age*

XS (4-6)Small (6-8)Medium (10-12)Large (14-16)

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone numberFormat: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Does your child have allergies that we need to know about?*

YesNo

By marking yes and signing below, I grant permission for my child(ren) to be photographed and/or recorded while participating in Clarinda Regional Health Center’s Garden Program. I understand that this content may be used in promotional materials, shared on social media, or other communications to highlight the program/healthy eating initiatives for CRHC. I also acknowledge that in certain situations, such as group/crowd shots, my child’s image may appear unintentionally to third parties (other parents). If I do not wish for my child to be photographed, I'll indicate this by selecting "no" on this form, and I will also agree to complete a declined Photo Consent form upon dropping off my child(ren) on the first day of class.

YesNo

Signature*

DateTime*

Child's Name #6*

First NameLast Name

Which session do you want your child to attend?*

Age*

XS (4-6)Small (6-8)Medium (10-12)Large (14-16)

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Phone Number*

Please enter a valid phone numberFormat: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Does your child have allergies that we need to know about?*

YesNo

By marking yes and signing below, I grant permission for my child(ren) to be photographed and/or recorded while participating in Clarinda Regional Health Center’s Garden Program. I understand that this content may be used in promotional materials, shared on social media, or other communications to highlight the program/healthy eating initiatives for CRHC. I also acknowledge that in certain situations, such as group/crowd shots, my child’s image may appear unintentionally to third parties (other parents). If I do not wish for my child to be photographed, I'll indicate this by selecting "no" on this form, and I will also agree to complete a declined Photo Consent form upon dropping off my child(ren) on the first day of class.

YesNo

Signature*

DateTime*