Plated Academy Dietary & Medical Intake Form
Share your child’s dietary needs, allergies, and medical details for safe participation.
Student Information
Student Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Allergies & Dietary Restrictions
Food Allergies
Dietary Restrictions
Vegetarian
Vegan
Gluten-Free
Halal
Kosher
Other (specify in notes)
Medical Conditions
Any medical conditions we should know about
Current Medications
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Physician Name
Family Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
OHIP Number
Terms Agreement
Terms, Conditions & Liability Waiver Please read carefully before submitting enrollment information. 1. Enrollment & Payment Enrollment is confirmed upon receipt of full payment. Spots are not held without payment. All program fees are listed in Canadian dollars and include taxes where applicable. 2. Refunds & Cancellations Full refunds are available up to 14 days before the start of a program. Refunds within 14 days are issued at 50%. No refunds are offered once a program has started, though make-up classes will be accommodated when possible. 3. Attendance & Make-Up Classes We do our best to accommodate make-up classes for missed sessions but cannot guarantee them. Please notify us as soon as possible if your child will miss a class. 4. Food Allergies & Dietary Restrictions Plated Academy is nut-free. We collect detailed dietary information during enrollment and accommodate allergies and restrictions where possible. We cannot guarantee a completely allergen-free environment due to ingredients used in classes. 5. Code of Conduct Students are expected to behave respectfully toward instructors, fellow students, and the kitchen environment. Plated Academy reserves the right to dismiss any student whose behaviour disrupts the learning environment, without refund. 6. Privacy Personal and medical information collected during enrollment is kept confidential and used only for the purpose of safely running our programs. We do not sell or share your information with third parties. 7. Liability Waiver & Release of Liability Assumption of Risk: I understand that participation in Plated Academy programs involves the use of kitchen tools, equipment, and food preparation activities, which carry inherent risks including but not limited to cuts, burns, slips, and allergic reactions. I voluntarily accept these risks on behalf of my child. Release & Waiver: I hereby release, waive, and discharge Plated Academy, Howard Seivright, and all their employees, instructors, contractors, and representatives from any and all claims, demands, or causes of action arising from my child's participation in any program, workshop, camp, or event. Medical Consent: In case of a medical emergency, I authorize Plated Academy staff to seek emergency medical treatment for my child. I confirm that the medical information provided at enrollment is accurate and complete. Photo & Video Release: I grant Plated Academy permission to use photos and video footage of my child taken during classes for promotional and marketing purposes, including social media, website, and brochures. I understand my child's full name will never be published. If I do not consent to this, I will notify Plated Academy in writing before my child's first class. Field Trips & Transportation: For any off-site activity, separate consent will be requested. I understand that Plated Academy does not provide transportation unless explicitly stated. Severability: If any portion of this waiver is found to be unenforceable, the remaining provisions remain in full effect. 8. Changes To These Terms Plated Academy reserves the right to update these terms at any time. Material changes will be communicated to enrolled families via email. 9. Agreement By checking the agreement box on the enrollment form, you confirm that you have read, understood, and agree to be bound by all sections of these Terms & Conditions, including the Liability Waiver & Release of Liability.
I have read and agree to the Plated Academy Terms & Conditions and Liability Waiver
*
I have read and agree to the Plated Academy Terms & Conditions and Liability Waiver
Submit
Should be Empty: