SoulSpace Ultimate Wellness Camp Registration Form

SoulSpace Ultimate Wellness Camp Registration Form

Please complete the form below to register.
June 29 - July 3July 6 - 10August 3 - 7August 10 - 14August 17 - 21
Child Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Desired Name:*
Please provide any medical conditions, allergies, dietary restrictions, or any other concerns/conditions:
Is there anything in general that we should know about your child?
Additional Siblings

First NameLast Name
Sibling Birth Date (if applicable):

MonthDayYear
Desired Name:
Please provide any medical conditions, allergies, dietary restrictions, or any other concerns/conditions:
Is there anything in general that we should know about your child?
Family Information
Parent/Guardian Name:*

First NameLast Name
Contact Phone Number:*

Area CodePhone Number
E-mail Address:*
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Relationship to Child:*

Photo Release Form

I grant permission to SoulSpace, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at SoulSpace Ultimate Wellness Camp for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by SoulSpace Ultimate Wellness Camp. I hereby release SoulSpace and its legal representatives from liability for any violation or claims relating to said images or video.
Yes, I grant permission.No, I do not grant permission.
Pick-Up Information

Please list any other people who have permission to pick up your child. They must have photo ID at pick-up.
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
General Release: I/We the parent(s) or guardian(s) of the minor child, hereby grant permission for my/our child to participate in all activities in and around the Sage Street Mill SoulSpace and/or its satellite locations as part of the purchased programs. In addition, I/we hereby grant permission for my/our child to participate in all field trips which may include travel off-campus, walking through wooded areas, wading and other activities, including, but not limited to those activities in the program description. Further, I/we agree to assume all risks and liabilities associated with my/our child's participation in said program(s) and to hold the Sage Street Mill SoulSpace and any of its agents or employees harmless from all claims which may arise as a result of such participation. In case of emergency, the Sage Street Mill SoulSpace has permission to take my child to the nearest hospital.

Camper Expectations: I understand that my child will treat all employees with respect, and if they do not adhere to expectations or disrupt the experience for other campers they will be sent home. If a camper is dismissed due to behavioral/social issues, tuition is not refundable.
Signature

Clear
First come, first served! Space is guaranteed upon receipt of registration and payment.

Payment methods:

-Cash

-Check made out to CEDC SoulSpace

-Venmo: Sage Street Mill CEDC or @Sagestreetmill

Mailing Address:

PO Box 415, North Bennington, VT 05257
Should be Empty:

SoulSpace Ultimate Wellness Camp Registration Form

Family Information

Emergency Contact Information

Pick-Up Information