Child Name
First Name
Last Name
Totally Well Kids Registration Form
Learning To Manage Emotions
Age
Gender
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
Please enter a valid phone number.
Parent / Guardian Information
Name
First Name
Last Name
Relationship to Child
Email
*
example@example.com
Terms and Conditions
I allow my child to participate in this program.
I hereby authorize Totally Well Inc, Totally Well Kids conductor, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.
I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Do you allow the organizers to take photos or videos during the activities of your child for advertising and marketing purposes that will be posted on social media?
*
Yes
No
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: