BLOOM Therapeutic Recreation - Fall program Registration Form

Bloom - Outdoor Learning - Fall program
Participant Information
Email address*
example@example.com
Participant Full Name*

First NameLast Name
Participant Age
Has the participant attended any of our other programs in the past?*

YESNO
If you have answered YES to the previous question, please state which programs they have attended in the past:
Where did you learn about our program?
Emergency Contacts
Emergency contact #1 (full name)*
Relationship to participant*
Emergency contact #1 (phone number)*
Emergency contact #2 (full name)
Relationship to participant
Emergency contact #2 (phone number)
Program choices

Our fall program will be offered over 8 weeks - beginning Sept 13th and ending November 3rd
Please select which of the following days and times the participant will attend:*

Monday Mornings (9am-12pm)Monday Afternoons (1-4pm)Tuesday Afternoons (1-4pm) - Unavailable FULL -Wednesday Mornings (9am-12pm)
* Note that participants who will chose the stay for a full day will be given the opportunity to have lunch on site between the 2 lessons/programs.
Any comments for this section
Personalized Support

Our fall program will be running in a 4:1 ongoing ratio between participants and educator, with the option of adding a 1:1 support worker for those who require more assistance in the program.
Would you be interested in accessing 1:1 support for the participant during program hours? (we will contact you with details and availability and will be billed separately)*

YesNoMaybe
Any comments for this section:
Transportation

We are hoping to help facilitate transportation to and from our program for our fall participants. We are aiming to provide you with the best low-cost options based on your location and frequency/needs.
Would you be interested in adding transportation to our site for an additional fee (to be billed separately)?

YESNO
If you have answered YES to the previous question, please add your neighborhood and nearest intersection below:
Any comments for this section:
Program Options & Payment

Select the number of half-day sessions the participant will be attending to reserve their space.

Select your preferred option:*

Option A - One (1) half-day per weekOne (1) half-day each week for 8 weeks

$250.00CAD

Option B - Two (2) half-days per weekTwo (2) half-days each week for 8 weeks

$375.00CAD

Option C - Three (3) half-days per weekThree (3) half-days each week for 8 weeks

$425.00CAD

Option D - Four (4) half-days per weekFour (4) half-days per week for 8 weeks

$500.00CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Credit Card Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Billing information
Full name *
Email Address*
Billing Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Should be Empty:

Bloom - Outdoor Learning - Fall program

Participant Information

Emergency Contacts

Program choices

Personalized Support

Transportation

Program Options & Payment

Billing information