Summer Camp 2025 Registration Form

Heartsong Summer Adventure Program 2025 Registration
Thank you for signing up for Heartsong Summer Adventure Program! We are so excited!

To secure your spot, we require a non-refundable deposit of $100 upon registration. We will send you an invoice for the remaining balance which should be settled by July 1st.

If you cancel with 30 days' notice, you will receive a refund minus your deposit. If your cancellation falls within 15 to 29 days before your start date, a 50% refund will be issued minus the deposit. If you cancel less than 15 days before your start date, we won't be able to provide a refund.

Please feel free to call, email or text me with any questions.

Looking forward to a great summer with the Heartsong crew!

Jamie

801-865-6612

jamie@heartsonglearningcoop.com
Child's Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender and Pronoun Preference
How old is your child?
Parent/Caregiver Contact 1

First NameLast NameRelation to Student
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caregiver Contact 2

First NameLast NameRelation to Student
E-mail
example@example.com
Phone Number
Address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select which weeks you would like to register for.

July 7th - 10thJuly 14th - 17thJuly 21nd - July 24thJuly 28th - July 31stAugust 4th - 7thAugust 11th - 14thAugust 18th - 21ndAugust 25th - 28thSeptember 2rd - September 4th (No camp on Monday)September 9th - September 11thSeptember 15th - September 18th
Please list what single days you would like to reserve.
Would you like extended care? If so when?
Please share anything that you feel would help us support your child in the best way possible. Are there particular behaviors that you would like us to be aware of or to respond to in a particular way?
In the interest of inclusion, does your family observe any specific cultural holidays, events or traditions that you would like us to know about? Does your family orient to a specific religion or faith that you would like us to know about?
Does your child have any health conditions (physical, mental, or emotional) of which we should be aware of?
Is your child allergic to bee stings? If so, do they carry an epi pen?
What medication is your child is currently on and describe? If none, please write none.
Does your child have any food allergies? If so, what?
Does your child have allergies to medications? If so, what?
Child's Health Insurance Information

Company NameIDPhone Number
Primary Health Care Provider
Name
Please list at least two people who can be contacted in case of an emergency if a parent/guardian cannot be reached. A contact persong should be someone who is readily available
Emergency Contact #1
First and Last Name
Phone Number
Please enter a valid phone number.
Emergency Contact #2
First and Last Name
Phone Number
Please enter a valid phone number.
Who, in addition to their parents, has permission to pick up your child from Heartsong learning days or activities?
MEDICAL EMERGENCY AUTHORIZATION
I/We may not be available to provide consent for medical treatment in the event that our child becomes sick or is injured during participation in a HLC authorized activity. If I/we are not available for such consent, it is my/our desire to have the best available medical treatment for my/our child. This form hereby authorizes Heartsong Learning Co-op and its staff to act on our behalf with respect to any required medical treatment decisions and consents until such time as I/we are able to provide these items. In the event that I cannot be reached in an emergency, I hereby give my permission to call 911 and/or contact a medical facility or physician selected by the HLC staff to secure proper treatment for my child. Notice is hereby given to any qualified medical personnel that this authorization is currently in effect and such personnel are directed to act upon such authorization without delay. I/We agree to assume financial responsibility for all expenses and bill incurred in any emergency requiring medical attention.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Notice of Nondiscriminatory Policy

Heartsong Learning Collective admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, sexual orientation, or national and ethnic origin.
Outdoor Play Liability Release

I understand that Heartsong Learning Programs take place entirely outdoors, and that there are risks which naturally occur whenever children are playing outside. I release Heartsong Learning Colective and staff from any liability for injuries that might occur as a result of participating in Heartsong Learning Collective Programs. My child is in good physical health and I will provide appropriate clothing for the weather.
I have read and agree to the terms above
Travel Release Form

I understand that Heartsong Summer Learining Collective uses our registered and fully insured "Adventure Van", a 12 person passenger van, to travel to nearby locations with enrolled participants. The van is fully equiped with booster seats and ensures proper safety precausions. I give Heartsong Learning Collective permission to take my child on field trips in this van during enrolled program hours. All trip locations and details will be disclosed the day prior via text or email.
I have read and agree to the terms above.
Photo Release
I understand that photographs taken of my child by HLC staff or representatives may be used on the school’s website or other programs or documents available to the general public. I hereby authorize the HLC and its agents, volunteers or representatives to copy, exhibit, publish or distribute any and all such photographs of my child, including composite or artistic representations, and to use the photographs in all forms and media for purposes of publicizing HLC programs or for any other lawful purposes. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my photograph appears. I also understand that HLC will not place any photograph of my child on the internet if the photographs are accompanied by any identifying information. I hereby hold harmless and release and forever discharge Heartsong Learning Collective and all of its representatives, volunteers, and their successors, from all claims, demands and causes of action which I, my heirs, or representatives have or may have by reason of this authorization.
I have read and agree to the terms above.I do not agree and do not want my child's photo to be taken
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please read the following information carefully. This registration form is subject to the following conditions:
I acknowledge that camp runs from 9:00-3:00. Pickup is promptly at 3:00pm. If you need extended care please contact us directly.*

Yes, I agree.
I understand that my child will spend the entirety of his/her time at Summer Camp outside regardless of the weather*

Yes, I agree.
I understand that all program fees are due July 1st, 2025.*

Yes, I agree.
Deposit is due upon registration. You may pay in full now via PayPal with a 3%fee, or send a check to Heartsong Learning Center 5685 Sand Rd, Bellingham WA 98226*

Yes, I understand.
THE PERSON(S) FINANCIALLY RESPONSIBLE FOR PAYMENT OF THIS STUDENTS EXPENSES MUST SIGN THIS ENROLLMENT CONTRACT. ALL PERSONS SIGNING WILL BE JOINTLY AND SEVERALLY LIABLE FOR FULL FEES AND OTHER FINANCIAL OBLIGATIONS HEREUNDER. I HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS OF THIS CONTRACT.
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Once you click submit, we will send you an invoice to collect the deposit and schedule payment. Once payment is recieved we will confirm your registration.

Thank you for choosing Heartsong this summer! It will be full of fun and beautiful memories.
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Heartsong Summer Adventure Program 2025 Registration