Social Service Providers: Summer Arts & Wellness Camp Registration Form

Social Service Providers: Arts & Wellness Camp Registration Form (School Vacations)

Social Service Providers please fill out Part 1 and Part 2 of this registration form. Summer Arts & Wellness programming for children ages: 5-12. Taking place inside beautiful Soul Space our special place for Yoga, Art, Wellness activities, and also outside on our nature trails along the creek and more! Hosted at The Sage Street Mill, 29 Sage Street, in the heart of North Bennington. Winter and Spring Arts & Wellness Camps: February 20-24th, 2023 and: April 17-21st, 2023 - Meeting time: 9-4pm - (M-Friday) - Fee: $275/week - $250 for siblings - Early drop off at 8AM: $50. Camps fill up quickly, so be sure to sign up early and secure your child's spot! Once we receive your completed registration form, we will contact you with confirmation and other info. For more information please visit sagestreetmill.com/summer-camps or email us at info@sagestreetmill.com
Camper Name*

First NameMiddle NameLast Name
Preferred Name/pronouns
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Name*
Guardian E-mail*
example@example.com
Mobile Number*
Emergency Contact Name*
Emergency Contact Number*
Relationship to the camper*
Please provide any medical conditions, allergies, dietary restrictions, or any other concerns/conditions:
Is the participant prescribed an inhaler or epi-pen? If yes, please explain any instructions.
Does your child have 1 on 1 support or other accommodations at school.
Additional Siblings
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Please provide any medical conditions, allergies, dietary restrictions, or any other concerns/conditions/accommodations:
Additional Comments
The Participant(s) and their legal Parent/Guardian understand that photographs, videotapes, and other recordings will be made of participants in the Activity, including the Participant. The Participant and their legal Parent/Guardian consent to those photographs, videotapes, and other recordings and the use thereof as part of a record of the Activity and to promote the Arts & Wellness Camp program on the website sagestreetmill.com on Facebook @SoulSpace and Instagram @29SageStreet*

I approveI disapprove
I hereby give my approval for my child’s participation in any and all activities prepared by The Summer Arts & Wellness Camp at the Sage Street Mill. In exchange for the acceptance of said child’s candidacy by The Arts & Wellness Camp program, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Sage Street Mill Programs and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against The Sage Street Mill/Sage Street Programs/SoulSpace including all counselors and affiliates, all participants of The Summer program. There is a risk of being injured that is inherent in all outdoor related activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.*

I approveI disapprove
As Parent and/or Guardian of the named child participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.Permission is also granted to The Arts & Wellness Camp Program and its affiliates including Directors, Counselors, and participant parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season.This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.*

I approveI disapprove
How did you hear about us?*

Word of mouthFacebookInstagramEmail/newsletterWeb searchFront Porch ForumOther
Select the Camp Session(s) you are registering for ($275 per camper/session. $250 for siblings/session)*

1st session: June 20 - 242nd session: June 27 - July 13rd session: July 4 - 84th session: July 11 - 155th session: July 18 - 226th session: July 25 - 297th session: Aug 1 - 58th session: Aug 8 - 12
Would you like to sign up for our Early Drop Off option at 8am (additional $50/week)

YesNo

Social Service Providers: Arts & Wellness Camp Registration Form (School Vacations)

Additional Siblings

Part 2: This section is for Social Service Providers only