Attendee Enrollment Form
To join a program, please submit one form per child on an annual basis. Feel free to email us with any questions or requests at tnlsteam@gmail.com. We look forward to seeing you in the Lab!
Attendee & Parent Information
Attendee Name
*
First Name
Last Name
Attendee's Date of Birth
*
/
Month
/
Day
Year
Current Grade/School/Teacher
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
First Parent/Legal Guardian's Name
*
First Name
Last Name
First Parent/Legal Guardian's Phone Number
*
Format: (000) 000-0000.
First Parent/Legal Guardian's Email Address
*
Second Parent/Legal Guardian's Name
First Name
Last Name
Second Parent/Legal Guardian's Phone Number
Format: (000) 000-0000.
Second Parent/Legal Guardian's Email Address
Medical & Behavioral Information
Please provide information on any medical, psychological or behavioral conditions, medications, dietary restrictions, allergies or special needs that we should be aware of to ensure that your child's experience is positive. If your child has no points of concern please write "N/A" in the box below.
*
Does your child require an MMA (Maryland Medication Administration Authorization) to dispense medication (such as an Epi-Pen) or an Asthma Action Plan?
*
No
Yes
MMA Form
If your child requires medication (for example, allergies requiring an Epi-Pen), please download a copy of the form below. Fill out this form and submit to tnlsteam@gmail.com at your earliest convenience. PLEASE DO NOT ATTEMPT TO FILL OUT THE FORM WITHIN THE PDF VIEWER.
Asthma Action Plan
If your child has need of an asthma action plan, please download a copy of the form below. Fill out this form and submit to tnlsteam@gmail.com at your earliest convenience. PLEASE DO NOT ATTEMPT TO FILL OUT THE FORM WITHIN THE PDF VIEWER.
Doctor's Name/Practice
*
Doctor's Phone Number
*
Format: (000) 000-0000.
Dentist's Name/Practice
Dentist's Phone Number
Format: (000) 000-0000.
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your name in place of signature below authorizes the NatureLab to have your child transported to that hospital.
*
First Name
Last Name
Emergency Contact Information
Please list up to three people who can be called in case of emergency if parents/guardians cannot be reached.
Emergency Contact #1 Name
*
First Name
Last Name
Relationship to child
*
Please Select
Grandparent
Aunt/Uncle
Babysitter/Nanny/Au Pair
Family Friend
Neighbor
Sibling
Other
Phone Number
*
Format: (000) 000-0000.
Emergency Contact #2 Name
First Name
Last Name
Relationship to child
Please Select
Grandparent
Aunt/Uncle
Babysitter/Nanny/Au Pair
Family Friend
Neighbor
Sibling
Other
Phone Number
Format: (000) 000-0000.
Emergency Contact #3 Name
First Name
Last Name
Relationship to child
Please Select
Grandparent
Aunt/Uncle
Babysitter/Nanny/Au Pair
Family Friend
Neighbor
Sibling
Other
Phone Number
Format: (000) 000-0000.
Please let us know how you learned about the NatureLab!
Print
Save
Submit
Clear All Questions
Should be Empty: