UES Farm & Forest Co-Op Registration

UES Farm & Forest Co-Op Registration

Pomaria, SC
Your Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Do you have multiple children you are registering? (a separate application is needed for each child, but please list their name(s) and age(s)*

Family Info
Does your learner have any siblings? Names and Ages?*
Tell us a little about your child. What are some of their interests? What makes them feel at home and safe (regulated) in their bodies? What have you observed about their development lately?*
Does your parenting approach already include following your child, letting them lead the way, encouraging autonomy, allowing free play, etc? Are you open to learning more about these concepts?*
Who does the child live with? Name(s) and relationship to child:*

Child Profile
Does this child have any allergies to food, products, medicines, etc.? If so, please list all allergies. *
Does this child have any physical limitations or differences? Please explain.*
Does this child have any dietary restrictions? Please explain.*
Does this child have any medical conditions previously or currently? If so, please explain.*
Does this child have any sensory and/or learning differences? If so, please explain. *
Please list this child’s favorite regulation methods i.e. song, book, walking, a game, activity, etc. *

Emergency Information
Primary Caregiver 1*

First NameLast Name
Primary Caregiver 1 Phone Number*
Please enter a valid phone number.
Primary Caregiver 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Caregiver 2 *

First NameLast Name
Primary Caregiver 2 Phone Number*
Please enter a valid phone number.
Primary Caregiver 2 Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Emergency Contact 3*

First NameLast Name
Emergency Contact 3 Phone Number*
Please enter a valid phone number.
Child’s Primary Care Practitioner*
By signing this form, I consent to the Team at UES providing first aid, emergency care, and contacting emergency services if and when applicable for this child.*

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Media Release
UES appreciates the usage of live-action photos and videos of learners at play and work to showcase our program. Please select one option below determining if we have permission to utilize photos and media of your learner on our social media, newsletters, website, etc. *

Child Pick-Up Authorization
Authorized pick-Up Person 1*

First NameLast Name
Authorized PIck-Up Person 1 Phone Number*
Please enter a valid phone number.
Relationship to Child*
Authorized Pick-Up Person 2*

First NameLast Name
Authorized Pick-Up Person 2 Phone Number*
Please enter a valid phone number.
Relationship to Child*
Authorized Pick-Up Person 3*

First NameLast Name
Authorized Pick-Up Person 3 Phone Number*
Please enter a valid phone number.
Relationship to Child*

Waiver
RELEASE & HOLD HARMLESS WAIVER OF LIABILITY AND INDEMNITY AGREEMENT 2024-2025 By signing this form I hereby voluntarily agree to release, waive, and fully discharge Unbound Earth School, LLC from any and all claims, demands, obligations and liabilities of any kind or nature whatsoever arising from or connected, directly or indirectly, with my/my child’s participation in the outdoor activity program due to any cause whatsoever. I accept that this release covers and includes, but is not limited to, all unknown and unforeseen claims, injuries, damages and losses, and any consequences thereof. I knowingly and voluntarily give up valuable legal rights, including the right to sue. This release shall extend to and include Unbound Earth School, LLC and the event organizer, partners, managers, officers, agents, contractors and volunteers including medical and paramedical personnel appointed for the activities, the owners, licensees, and occupiers of land on which the activities or any part of it are conducted or which is involved directly or indirectly with the activities in any manner whatsoever. This release and indemnity continues forever and binds my heirs, executors, personal representative and assigns. Participation in the activities at Unbound Earth School, LLC carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I acknowledge the risks involved in the activities conducted at Unbound Earth School, LLC. These risks or dangers may be caused by other participants, or by accidents, or by forces of nature or other causes. I further understand and agree that there may be risks and dangers not known or reasonably foreseeable at this time. I have read this waiver of liability, assumption of risk and indemnity agreement, fully understand its terms and I understand that by signing this document I hereby release Unbound Earth School, LLC from any and all liability associated with the program my child is attending. I understand that I give up substantial rights by signing it, and sign it voluntarily.*

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Program Choice

Please select the appropriate product below.
My Products
prevnext( X )
Drop-Off Co-OpStudent #1, 1 month
$300.00 Quantity



Drop-Off Co-OpStudent #2 or #3, 1 month
$200.00 Quantity



Drop-Off Co-OpStudent #4+, 1 month
$ Free Quantity



Family Co-OpCaregiver Stays, 1 month
$150.00 Quantity



ScholarshipYou will need preapproval for this option. Contact us for more info.
$ Free Quantity



Family Co-Op, child #2+
$ Free Quantity



Total

$0.00
Month you’d like to register for:
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UES Farm & Forest Co-Op Registration

Family Info

Child Profile

Emergency Information

Media Release

Child Pick-Up Authorization

Waiver

Program Choice