REGISTRATION FORM
Parent/Guardian's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Which day do you intend to enroll, Monday, Thursday, or Friday?
*
Child's Name
*
First Name
Last Name
Child's Current Age
*
Child's Birthdate
*
-
Month
-
Day
Year
Date
How will you be paying?
*
ESA Direct Vendor Pay
Cash or Venmo
Can child perform physical activities such as hiking and climbing rocks in nature?
*
Yes
No
Does your child have any physical limitations that staff needs to be aware of?
*
Yes
No
If yes, please explain... (Example: My child cannot swim)
Does child have any allergies or any needs that staff needs to be aware of?
*
Yes
No
If yes, please explain...
Will you be providing an EpiPen for your child in case of an allergic reaction?
*
Yes
No
If you are providing an EpiPen, does staff have permission to administer that EpiPen in the event that your child has a severe allergic reaction?
Yes
No
Not Applicable
Does Outdoor Adventure Kids have permission to use pictures of your child for social media/marketing purposes?
*
Yes
No
Does Outdoor Adventure Kids have permission to administer basic first aid (band-aids, Benadryl, ibuprofen) if needed?
*
Yes
No
Please state any that is not acceptable
EMERGENCY CONTACTS: (please list two)
Emergency Contact Name #1
*
Phone
*
Format: (000) 000-0000.
Emergency Contact Name #2
*
Phone
*
Format: (000) 000-0000.
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