Wild Soul Registration Form 24/25

**Please complete the form and press submit at the bottom. Thank you!!**

Child's Name

First NameLast Name

Date of Birth

Date

Parent/Guardian 1

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Parent/Guardian 2

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I am registering for (please select all that apply):

Monday Leaf Hoppers (5-6 year-olds)Wednesday Leaf Hoppers (5-6 year-olds)Monday Wild Tenders (7-12 year-olds)Wednesday Wild Tenders (7-12 year-olds)

Does your child have any allergies or environmental sensitivities?

Has your child been stung before and was there any significant reaction?

Is your child taking any medications?

Does your child have any issues which would affect their abilities to be outdoors, interact with other children/adults and/or follow basic instructions? If yes, please explain.

Please list the full name and phone number of any additional adults that are authorized to pick up your child (ID will be required):

By typing my name in below, I am agreeing to register my child for the programs indicated and will be responsible for payment at the rate discussed. I understand that I will need to submit a $200 deposit in order to reserve my child's spot, and that this deposit may not be refundable should I decide to withdraw.

**Please note: registration does reserve you a spot, but does not guarantee acceptance into the program. While we will do all we can to make our programs accessible to all, we reserve the right to ensure we are a good fit for each other and that it is within our ability to meet your child's needs before their spot is guaranteed. If for some reason we decide we are not a good match, your deposit will be fully refunded.

We also reserve the right to cancel programs that do not have adequate enrollment. For our fall programs, cancellation decisions will be made by July 1st. You will be notified by email and/or phone if changes are made to any program you are registered for. Your deposit will be refunded in the case of cencellation. Thank you!**

Parent/Guardian Name (E-signature) and date:

Photo Permission

Please indicate which option you would prefer below. Photos will be used solely for the purpose of promoting our program.

In regards to using photos of my child:

any shot is finephotos that do not show faces are OKfor any photo, please ask permission first!NO photos of my child should be used to promote Wild Soul

Parent/Guardian Name (E-signature) and Date:

Financial Acknowledgement

By registering, you agree to pay the full cost of the program in which your child is enrolled, according to the payment plan agreed upon by you and Wild Soul. Refunds given as a result of withdrawal from the program will be decided on a case-by-case basis, and all refunds will be minus a 5% service charge. We require a minimum of 30 days notice before leaving or withdrawing from the program. We cannot provide refunds for days missed due to illness, travel or inclement weather.

By signing below, you acknowledge that you have read and understand our financial policies.

Waiver and Release of Liability form

Participation
I hereby give permission for my child to participate in any/all activities as provided by Durango Wild Soul and Onward! A Legacy Foundation. I agree to notify staff if there are any activities which should be avoided for any reason.

Inclement Weather
I understand that inclement weather can be dangerous and pose certain risks for participation. I further understand that it is my responsibility to provide weather-appropriate clothing for my child and that Durango Wild Soul reserves the right to change location, cancel or make appropriate changes in plan to accommodate unsafe or problematic weather.

Responsibility for Injury/Accident
I understand that Durango Wild Soul program and staff or Onward! A Legacy Foundation, will not be held liable for illness or injury to my child caused by, or that occurs during, participation in the program. I hereby waive, absolve, indemnify and agree to hold harmless parents, facilitators, participants and owners of the land where the program is held from any injury or accident that occurs while participating.

Emergency Care
I agree that in the event of emergency, Durango Wild Soul and its facilitators may use their best judgement to provide and/or seek treatment or first aid for my child until such a time as I can be reached and/or present. This applies to circumstances such as the need for CPR, cleaning wounds, calling EMS and/or going to the ER, and administering medication to treat acute conditions such as allergic reactions or snakebite.

Release of liability
I release, waive and fully discharge Wild Soul, Onward! A Legacy Foundation, and all their staff from any and all claims, demands, obligations and liabilities of all kinds arising from or connected, directly or indirectly, with my participation in this program due to any cause whatsoever, including negligence, and I accept that this release cover and includes, but is not limited to, all unknown and unforeseen claims, injuries, damages and losses and any consequences thereof.

This release shall include Wild Soul and Onward! A Legacy Foundation and its facilitators and organizers, parents, participants, volunteers, contractors, medical and paramedical personnel, owners, licensees and occupiers of land on which the activities are held or anyone who is involved directly or indirectly with the activities in any manner. This release and indemnity continues forever and binds my heirs, executors, personal representative and assigns.

Parent/Guardian Name (E-signature) and Date:

By typing my name below, I agree to the terms set forth above.

Child's Name

First NameLast Name

Parent/Guardian Full Name (E-signature):

Date:

Date

Please submit your deposit online at the link provided on our website here: www.durangowildsoul.org/program-details.html

Thank you! We are excited to have you join us!

Durango Wild Soul is a fiscal fund of Onward! A Legacy Foundation