FP Program Registration

CONTACT INFORMATION (Primary Guardian)
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Authorization

Emergency ContactCan Pick-Up Student
Relationship to Student
CONTACT INFORMATION (Other Adult)
Full Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Authorization

Emergency ContactCan Pick-Up Student
Relationship to Student

HEALTH INFORMATION

Your child's health and safety are important to us. Please be complete when filling out the following information, as it is our primary resource in case of emergency.
1. List any medical, physical, emotional, behavioral or social conditions that may affect your child's experience. Please also include any relevant medical treatment. If none, write 'none'.
Please provide any additional information or special tips to help us address these conditions at Feelosopher's Path.
2. List your child's allergies and dietary restrictions. If none, write 'none'.
Please describe the type and severity of reaction if your child is exposed to allergens as well as the requested course of action if an allergic reaction occurs:

MEDICATIONS AND IMMUNIZATIONS
Does your child require an EpiPen?

YesNo
Is your child up to date on all state-required immunizations?

YesNo
When was your child's last Tetanus shot?
Will your child require any medications while at the program?

YesNo
If yes, please include reason for taking it, dosage and frequency:
I authorize Feelosopher's Path and its staff to provide non-prescription medications as deemed appropriate. I understand that they will attempt to contact me before administering any medication.

YesNo

WAIVER
I, the undersigned parent/guardian of the above named student, do hereby consent to his/her participation in the Feelosopher's Path Program.*

I agree
I agree to follow Feelosopher's Path current COVID protocols and will notify them if any symptoms or exposures occur.*

I agree
I acknowledge that participation in this program may expose the above named student to the possibility of injury. I grant Feelosopher's Path staff the authority to obtain emergency medical treatment as necessary to insure that the above named student is safe from further injury.*

I agree
I understand that while Feelosopher's Path staff strive to make the program as safe as reasonably possible, there exists always the possibility of injury or death due to the negligence of Feelosopher's Path staff before or after an injury occurs. Negligence means the failure to exercise the due care that a reasonable person would exercise under the circumstances. By signing below I hereby waive my right to pursue legal action based upon illness, injury, or death to my child.*

I agree
I hereby agree to indemnify and hold harmless Feelosopher's Path from any loss, liability, damage, or cost of any and all kind they may incur due to the participation of the above named student in the program and any activities incidental thereto, whether caused by the negligence of Feelosopher's Path or otherwise.*

I agree
I am aware that the above named student may appear in a photograph, or video, taken by staff or local media and that that photograph or video may appear in a variety of media sources on behalf of Feelosopher's Path. Feelosopher's Path will not divulge your child's name without written permission.*

I agree
I acknowledge that the above named student will be participating in activities, trips and events organized by Feelosopher's Path. I am aware that the participation of my student may be outside the scope of his/her daily routine. I give permission for my child to travel by foot, automobile, bus, train, or ferry to a desired location.*

I agree
Primary Guardian
Authorization Date

MonthDayYear
Please verify that you are human*