WKA 2025-26 Registration Form

Wilderness Kids Alexandria 2025-26 Registration Form

Wilderness Kids Alexandria (WKA) exists to provide life-enriching experiences in nature to middle-school and high-school students from under-resourced families or under-served communities in the City of Alexandria. We offer both one-day outings and overnight camping trips to our students throughout the year. We look forward to spending time with your child in the great outdoors! Before we do that, we need you to complete the form below.
Student Name:*
Date of Birth: *

MonthDayYear
Date
Gender (select one):*

FemaleMaleNon-Binary
Grade (select one):*

6789101112
School
Pick-up and Transportation to Programs

During our After-School Program, Club Program, and occasionally Cohorts, we will pick up your child (sometimes referred to herein as the "participant") from their school after classes have ended and drive them to a park or natural area in or around Alexandria, spend approximately 60 to 90 minutes there participating in various activities, and then drop your child at their regular bus stop or at home after the program.

The Weekend Programs, and sometimes Cohorts, will take place on weekends and weekdays on which classes are off, as determined by WKA at the start of the Program. During Weekend Programs, we will pick up your child at a specified location and time to be agreed with you on a rolling basis. We will drive them to a park or natural area in or around Alexandria, participate in various activities, and stay for an amount of time there agreed with families for that given day. We will then drop your child at a place and time to be agreed with you on a rolling basis after the Weekend Program.

The Summer Programs will take place in June, July and August. Transportation arrangements will be made with parents, in similar fashion to the Weekend Programs. Distances traveled will be greater and will be explained at the time of the Program. From here forward, the After-School Program, Club Program, Weekend Outings, Cohorts, and Summer Program are collectively referred to as the "Programs."

I give permission for WKA to pick my child up from either: their school after classes have ended, or from the specified location and time I agree to from time to time, as applicable, and to drive them to destinations for the Programs whether by car, van, bus or similar transportive means, where the Programs will take place on such day. Locations for Programs on school days may include, but are not limited to: Dora Kelley Nature Park, Huntley Meadows Park, Roosevelt Island and other natural areas in and near the City of Alexandria. Locations for Programs on days without school may include natural areas in Virginia, West Virginia, Maryland, and Washington DC, or farther away during Summer. I give permission for WKA staff to choose the location of the activity based on the schedule of the applicable Program on any given day.

Drop Off After the Programs

I give permission to WKA to drop my child off after each Program at any of: my child's typical bus stop, in front of my child's residence, or at the specified location and time I agree to from time to time, as applicable (the "drop-off spot" Further, I give permission for my child to be dropped without an adult present to collect them at the drop-off spot. I understand that WKA intends to drop my child off between 5:30 p.m. and 6:00 p.m for programs taking place on school days, and that WKA will inform me of drop-off times for each program on days without school.

I recognize that some circumstances, including weather, traffic, road conditions, and others, are beyond the control of WKA, and consequently drop off times may be later or earlier than planned. In those cases, WKA staff will try to inform me of delays or early drop-offs. I agree that WKA is no longer responsible for my child after he or she has been dropped off at the designated drop-off site, and release WKA, its staff, agents, employees, managers, volunteers, operators and representatives from any liability for any injury experienced by my child following drop off.

In summary, I give permission for my child to be picked up by WKA for the corresponding Program, driven to a Program location by WKA, and then dropped off at a specified bus stop, the child's home, or a specified location to be agreed on, as applicable, by WKA at the end of the corresponding Program.
ParentGuardian Name*
ParentGuardian Signature*

Clear
Relation to Student (parent, grandparent etc.):*
Email Address (If you do not have email, write "no@no.com"):*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Second Phone Number:
Student Information
(Optional) What race or ethnicity best describes your child? We ask this in order to have a general understanding of the racial and ethnic identities of the young people we serve. Please check all that apply; or if none describes your child well, please use the "Other" box to describe your child's race or ethnicity.

American Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific IslanderWhiteBlack or African AmericanHispanic or Latina/o/xMiddle East or North AfricanMultiracialI prefer not to answerOther
Check a box for each form of government assistance for which your family qualifies, if any (even if you do not receive such assistance:*

SNAP (Food Stamps)Free & Reduced LunchMedicaidTANFCHIPWe do not qualify for government assistance.
Check a box if your child:

Speaks English as a second languageis a recent immigrant, refugee, or asylum seeker to the USAis in the foster care systemhas an absent or deceased-parent(s)
Are there other programs similar to WKA that your child already participates in?*

Boy Scouts/Girl ScoutsSummer Outdoor CampsOutdoor Adventure ProgramsMy child does not have the opportunity to participate in similar programsOther
Please describe other challenges disadvantages hardships or situations that you and/or your child face that make it difficult for your child to access other programs similar to WKA and/or that would make WKA an especially valuable program for your child?
Does your child have any allergies to medications? (Select One)*

YesNo
If Yes, please explain what they are allergic to, the reaction they have when exposed (how severe is it), and the medication they take, or steps that they follow, if any, to resolve the problem?
Does your child have any environmental or food-related allergies or food restrictions? (Select One)*

YesNo
If Yes, please explain what their restrictions are or what they are allergic to, the reaction they have when exposed (how severe is it), and the medication they take and steps they follow, if any, to resolve the problem?
Does your child currently take any medications? (Select One)*

YesNo
If Yes, please list all medications, including non-prescription and over-the-counter medications. List what it is for (condition/symptom), the dosage (how much/how often), the start date, and side affects (if any):
Has your child been diagnosed with any of the following conditions:

AsthmaAutism/Autistic SpectrumDiabetes - Type 1Diabetes - Type 2AnxietyEating disorder - Anorexia/Bulimia/Binge-eating/AFRID/OtherOther
How well does your child swim?*

StrongIntermediateBeginnerDoesn't swim
How well does your child ride a bike?*

StrongIntermediateBeginnerDoesn't swim
If you answered yes to any of the above conditions OR IF YOU HAVE ANY OTHER INFORMATION ABOUT YOUR CHILD THAT YOU WOULD LIKE TO SHARE please describe the plan used to manage the condition or your concerns:
Student Conduct

I understand that alcohol, tobacco, vaping devices, and drugs are prohibited on all WKA Programs and agree that my child may be removed from programs if they possess such items. I also understand that my child’s cell phone can become a distraction to their experience with WKA and acknowledge that during After-School and Club Programs, students will be asked to turn their phones over to WKA staff for the duration of the Program. I acknowledge that cell phones are completely prohibited on Programs that occur on non-school days, including Weekend and Summer Programs.”

Participant Waiver, Assumption of Risk, and Agreement of Release and Indemnity Please read and sign this statement. Contact us if you have any questions regarding this statement.

In consideration of Wilderness Kids Alexandria Inc, its directors, employees, officers, volunteers, trustees, contractors and all other persons or entities associated with it (collectively referred to as "WKA") allowing my child or legal ward to participate as a participant in the after school Program provided by WKA, I, the student or other participant participating in the activities described below (in either case, the "Participant"), or the parent or legal guardian of a minor Participant, hereby enter into this agreement (this "Agreement") and acknowledge and agree as follows:

Acknowledgment and Assumption of Risks

I understand and acknowledge that the activities the Participant participates in with WKA, including but not limited to camping, including cooking over stoves, open fires or by other means, kayaking, canoeing, skiing, rock climbing, sailing, surfing, swimming, hiking, biking, horseback riding, caving, vehicle travel, service projects that may involve using tools, power equipment, ladders, or construction materials and other related activities (the “Activities”), may be dangerous and may involve the risk that my child will sustain serious injury, illness, temporary or permanent disability, paralysis, trauma, death, and/or property damage. I understand that the Activities may not be supervised, and that WKA does not provide medical services beyond basic first aid. I further acknowledge that any injury that my child may sustain while participating in the Activities may be compounded by negligent or delayed medical service or negligent or delayed assistance by WKA. I further acknowledge there may be other risks and economic losses, which may not be known to me or may be unforeseeable, that are presented by my child’s participation in the Activities. I VOLUNTARILY AND FREELY ASSUME ALL RISKS AND DANGERS THAT MAY OCCUR IN CONNECTION WITH THE PARTICIPANT’S PARTICIPATION IN THE ACTIVITIES, INCLUDING THE RISK OF INJURY, DEATH, OR PROPERTY DAMAGE, EVEN IF CAUSED BY NEGLIGENCE OF WKA.

Agreements of Release and Indemnity

I hereby fully and forever release, hold harmless, and agree not to sue WKA, its agents, and staff, including managers, interns and all other persons, representatives or entities acting under their direction ("Released Parties"), with respect to any and all claims or losses of any kind I may currently or hereinafter have, including, but not limited to, claims of loss or damage to person or property by reason of injury, temporary or permanent disability, death, damages, liabilities, expenses and/or causes of action, now known or otherwise suffered by the Participant, arising in whole or in part from my, or the minor Participant's, participation in the WKA program or any Other Programs, whether caused by the negligence of WKA or any of the Released Parties or by any other reason. I agree further to indemnify ("indemnify" means to defend, and pay or reimburse, including costs and attorney's fees) Released Parties against any claim or loss brought or caused by a member of my or the minor Participant's family, a rescuer, another participant, or any other person, which claim or loss arises in whole or part from an injury or other loss suffered by me or caused by me, or suffered or caused by the minor Participant, in connection with my, or the minor Participant's, participation in the WKA program or any Other Program.

I acknowledge and agree that this release and waiver of liability is intended to be, and is, a complete release, to the full extent allowed by applicable law, of any responsibility of the Released Parties for all personal injuries, temporary or permanent disability, death, and/or property damage sustained by my child while participating in the Activities. I agree, on behalf of myself and the minor Participant, to accept and abide by WKA honor code and rules and that violating these rules and regulations could place the Participant and others in danger of injury or death. I understand and agree that WKA may search my, or the minor Participant's, belongings at any time in search of prohibited or other items. I agree that this Agreement and all other aspects of my, or the minor Participant's, relationship with WKA, contractual or otherwise, are governed by the laws of Virginia. TO THE FULLEST EXTENT PERMITTED BY LAW, I HEREBY WAIVE ALL RIGHTS TO A TRIAL BY JURY IN ANY LEGAL ACTION TO ENFORCE OR INTERPRET THE PROVISIONS OF THIS AGREEMENT OR THAT OTHERWISE RELATES TO THIS AGREEMENT.
I, the Participant, or my parent(s) or guardian if I am a minor, have carefully read, understood and accepted the terms and conditions stated herein and acknowledge that this Agreement shall be effective and binding upon myself, my heirs, assigns, personal representatives and estate and all members of my family.
Participant/Parent/Guardian Name: *
Participant/Parent/Guardian Signature: *

Clear
Medical Authorization & Release

I have verified with the physician, or other medical professionals of my child, or otherwise satisfied WKA, that my child has no past or current physical or psychological condition that might affect his/her/their participation in the WKA Program. My child is able to participate without causing harm to himself or herself or to others. I understand that WKA admission of the Participant to the Program is not intended as a representation that WKA staff will be able to manage successfully a medical event or emergency related to a disclosed, or undisclosed, medical condition. The responsibility for determining a student’s suitability for a course is not WKA's but, rather, the Participant's, guided by family and her or his or their physician. WKA reserves the right to refuse admission or remove a Participant from a Program for any reason it deems in the best interests of the student or of WKA. WKA is authorized to obtain emergency hospitalization or other medical care for the Participant.
With my signature on this form, I authorize WKA staff to administer the following over-the-counter products and medicines to my child as deemed necessary by WKA staff (choose all that apply):*

None. None of the below may be given to my child.Tylenol (or Acetaminophen)Advil (or Ibuprofen)Bismuth subsalicylate (Pepto Bismol)SPF SunscreenCalcium Carbonate (Tums)Insect Repellent with DEETBenadryl (for allergic reaction)Cough DropsTopical Hydrocortisone (for itching)
Participant/Parent/Guardian Name: *
Participant/Parent/Guardian Signature: *

Clear
Consent to Disclosure of Personal Information

The Participant, or the parent or legal guardian of a minor Participant, understands and acknowledges that WKA may wish to disclose personal information about Participants, including their name, image, voice, and/or personal story collected during or in connection with participation in WKA activities for purposes of grant proposals and other financial support, promotional materials, community awareness, and other reasons, to third parties, including but not limited to social media platforms (e.g., Instagram, Facebook, Twitter, etc.). I understand that I am under no obligation to consent to the disclosure of my/my child or ward's personal information. I further understand I can withdraw my consent by notifying WKA's Executive Director in writing.
Having been fully informed and considered the above, I authorize WKA to have my, or the minor Participant's, image, voice, name, and/or story collected during or in connection with participation in any activity with WKA or otherwise provided to WKA, and use such image, voice, name and/or story in any format, including video, print or electronic as WKA may deem appropriate to carry out its mission, including on the website and social media sites.
Participant/Parent/Guardian Name:
Participant/Parent/Guardian Signature:

Clear
Should be Empty:

Wilderness Kids Alexandria 2025-26 Registration Form

Pick-up and Transportation to Programs

Drop Off After the Programs

Student Information

Student Conduct

Participant Waiver, Assumption of Risk, and Agreement of Release and Indemnity Please read and sign this statement. Contact us if you have any questions regarding this statement.

Acknowledgment and Assumption of Risks

Agreements of Release and Indemnity

Medical Authorization & Release

Consent to Disclosure of Personal Information