Weekly Programs - 2023
Please complete a separate registration form for each child.
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Age
*
Preferred Pronoun
She/Her
He/His
They/Them
Prefer not to say
Cedervale Weekly Programs
Please fill in the time and day of your program(s) below (Cedarvale Ravine) $270/week
March 13th, 2023 - March 17th, 2023 (9am-12pm)
March 13th, 2023 - March 17th, 2023 (1pm-4pm)
April 3rd, 2023 - April 7th, 2023 (9am-12pm)
April 10th, 2023 - April 14th, 2023 (9am-12pm)
Other
Cedervale PA day Programs
Please fill the day of your program(s) below (Cedarvale Ravine) $54/day
January 13th, 2023 (9am-12pm)
February 17th, 2023 (9am-12pm)
April 7th, 2023 (9am-12pm)
May 22nd, 2023 (9am-12pm)
June 2nd, 2023 (9am-12pm)
Other
Additional notes;
Back
Next
Parent/Guardian Information
Parent/Guardian 1
*
First Name
Last Name
Preferred pronoun
She/Her
He/His
They/Them
Prefer not to say
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Parent/Guardian 2
First Name
Last Name
Prefferred pronoun
She/Her
He/His
They/Them
Prefer not to say
Email
example@example.com
Phone Number
Please enter a valid phone number.
Back
Next
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to Child
*
Approved Names for Pickup (please separate names with a comma)
*
Back
Next
Medical/Health Information
Does your child have any food, medication or environmental allergies?
*
Yes
No
Please list and explain any allergies
Does your child's allergy require staff to monitor them for symptom, take action if a reaction occurs, or provide emergency medication to them?
Yes
No
Requires an Epi Pen
Does your child have a special health or medical condition?
*
Yes
No
If your child has a special health or medical condition, please explain here.
Please provide any additional information about your child that would be useful for the Roots 2 Rise staff to be able to best support your child's needs (i.e. emotional, cognitive, behavioural, physical, etc.)
Back
Next
Name
*
First Name
Last Name
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Thank you for your interest in Roots 2 Rise Outdoors!
Once your group has the minimum participants required for confirmation, the payment information, waiver and program information package will be sent to you.
Submit
Should be Empty: