Grade 5/6 Spring Registration

Grade 5/6 Wed. and Thur Program Registration

Spring 2023 Thursdays March 23rd to June 15th, 2023
Child's Full Legal Name:*

First Name(s)Last Name(s)
Child's Age:*
Date of Birth:*
YYYY/MM/DD
Gender Identity: *
Ministry of Education reporting requirement
Current School and Grade:*
Name of School Grade
Known Allergies:*
All students with anaphylactic allergies are requested to complete an Individual Allergy Plan.
Known Medical Conditions and/or current medication:*
Please advise if medication will need to be taken at school.
Parent/Guardian #1 Information*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Home

Area CodePhone Number
Phone Number - Work

Area CodePhone Number
Phone Number - Mobile

Area CodePhone Number
Email*
example@example.com
Occupation*
Parent / Guardian # 2 Information

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Home

Area CodePhone Number
Phone Number - Work

Area CodePhone Number
Phone Number - Mobile

Area CodePhone Number
Email
example@example.com
Occupation
Child reside with...?*

Both ParentsMother onlyFather only
Are there any custodial arrangements which the school should be made aware of?*
Emergency and Pick Up Information
Emergency Contact (if parents are not available):*

First NameLast Name
Phone Number:*

Area CodePhone Number
Relationship to Child:*
Individuals authorized to pick up child:

Please note, the child will only be released to the Parents/Guardians listed above, or persons noted on this list, unless special case arrangements have been made with the office/Nature Connect staff members prior to pick up on any given day.
Additional Information
Language(s) spoken at home:*
Dietary restrictions:*
Name(s) and age(s) of sibling(s)
Tell us about your child:

Please take time to tell us about your child. The more we know, the easier it is to make their experience a success. Note that this program will bring the students outdoors in all types of weather and does require that they walk to local areas nearby.
What do you hope your child will receive from this program?*
Describe your child in a few words?*
What are your child's interests or hobbies?*
Please describe your child's experience with nature/outdoors?*
How would you describe your child's social/emotional development?*
Please describe your child's fine and gross motor development. Have there been any challenges?*
Does your child have any health conditions that we should be aware of?*
Have you ever sought counselling or a professional evaluation of your child?*

NoYes
If yes, please provide relevant details.
Is there anything else you feel we should know about your child?
Payment Details and Terms of Registration
Fees:*

Thursday Learning Block $585 (13 sessions) 9:30 to 2:30
An invoice will be sent confirming registration. Please wait for the invoice before proceeding with payment. The following payment options will be available:

e-transfer to ottawawaldorfprograms@gmail.comcheque made out to Polaris School and Centre
In mid April/beginning of May we are planning to offer more programming for this age group. Let us know if you would be interested in learning more:

Grade 5/6 Botany - Friday mornings from 9 am to 12 pmArchery - Wednesdays 11:30 am to 12:30 pmLeather and needle felting workshops - Wednesday mornings
Unless indicated to the contrary below, we are aware that Polaris School and Centre may use our child's photograph and/or pictures of their projects in external and internal marketing.

No - Polaris School and Centre may not use my/our child's photographs for external marketing.No - Polaris School and Centre may not use photos of my/our child's work or art or put it on display.
We acknowledge by signing below;*

We understand that we are registering our child for a full Term and that we will not be reimbursed for any classes missed during this time.
Signature - Parent(s)/Guardian(s)*

Clear
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Grade 5/6 Wed. and Thur Program Registration

Emergency and Pick Up Information

Additional Information

Tell us about your child:

Payment Details and Terms of Registration