Wild Things Registration Form

Wild Things Registration Form

Complete the registration form using the extracted PDF fields.
Child & Parent/Guardian Information
Child’s Name

First NameLast Name
Child’s Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian #1 Name

First NameLast Name
Parent/Guardian #1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Signature
Date

MonthDayYear
Date
Photo Permission Consent
Parent/Guardian Signature (Photo Permission)
Date (Photo Permission)

MonthDayYear
Date
Participant Information
Child’s Full Name

First NameMiddle NameLast Name
Preferred First Name
Birth Date

MonthDayYear
Date
Parent/Guardian Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Alternate Daytime Phone
Please enter a valid phone number.Format: (000) 000-0000.
Child’s Physician’s Name
Physician’s Number
Please enter a valid phone number.Format: (000) 000-0000.
Child’s OHIP Number
Health, Restrictions, and Medication
Activity Restrictions

Yes
Activity Restrictions Details
Allergies

Yes
Allergies Details
Asthma

Yes
Asthma Details
Dental (Braces/Retainer?)

Yes
Dental Details
Diet Restrictions

Yes
Diet Restrictions Details
Seizures

Yes
Seizures Details
Vision (Glasses/contacts?)

Yes
Vision Details
Other Health Condition

Yes
Other Health Condition Details
Is your child currently taking any medication?
Medication List and Intent
Additional Health / Mental / Physical Information
Medication Permissions
Permission to administer over-the-counter/homeopathic remedies
Tylenol
Ibuprofen
Rescue Remedy
Permission to administer prescriptions/medications provided by parent/guardian
Parent/Guardian Signature (Medication Permission)
Date (Medication Permission)

MonthDayYear
Date
Participant and Liability
Participant’s Name (please print)
Participant’s Signature
Date (Participant Signature)

MonthDayYear
Date
Name of Parent/Guardian (please print)
Signature of Parent/Guardian (Release of Liability)
Date (Parent/Guardian Release of Liability)

MonthDayYear
Date
Share contact information for car-pooling?
Should be Empty:

Wild Things Registration Form

Child & Parent/Guardian Information

Participant Information

Health, Restrictions, and Medication

Medication Permissions

Participant and Liability