Registration & Payment Form
for Wonder Roots Program Participation
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Participant Information
Date
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Month
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Day
Year
Date
Name of Participant
*
First Name
Last Name
Birth Date of Participant
*
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Month
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Day
Year
Date
Participant Contact Info
Emergency Contact 1 Info (Parent/Guardian if Participant is a Minor)
Emergency Contact 2 Info
Other Adults with Permission to Pick-Up
Does the named participant have any medical conditions, allergies, medication or issues or specific developmental needs that we should know about? Please describe:
*
Is there any other condition that we should be aware of that may endanger, alter, or somehow limit the named participant's abilities to participate in any Wonder Roots Program?
*
I do GIVE permission for Wonder Roots Staff to administer or apply the following:
Lotions (including subscreen)
Bug Spray
Ointments (such as salve or bug bite cream)
Photo & Media Permission
I do GIVE permission to have photo/video taken of named participant .
I do NOT GIVE permission to have photo/video taken of named participant.
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Last Step!
Signature & Payment. Your registration will automatically be submitted after payment.
Signature of Participant or Parent/Guardian of Minor Participant Named Above
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Print Name
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First Name
Last Name
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Tuesday Curiosity Connections: Session 2
$
220.00
Farm & Forage: Gardens, Chickens & Forest Fun Dates: Tuesday May 16, 23, 30. June 6. Time: 9:00-2:00 pm Location: 640 Texas Hill Rd. Hinesburg, VT 05461 Ages: 5-12
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