Registration

Student Name *

First Name

Last Name

Student Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Caregiver Name

First Name

Last Name

Parent/Caregiver Address

Please provide if different than Student

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Parent/Caregiver

First Name

Last Name

Program *

For Fall and Spring: Please chose Fall and/or Spring and how many days your child will attend.

Fall 2024-2025 (check one below also)

1 day

2 day

3 day

Spring 2024-2025 (check one below also)

1 day

2 day

3 day

Summer 2024 Bay June 1-27, 2024 (Check all that apply)

Drop in "Put dates in Notes"

Put Dates in the "Notes Regarding Enrollment"

Week 1 6/4/23-6/6/23

Week 2 6/11/23-6/13/23

Week 3 6/18/23-6/20/23

Week 4 6/25/23-6/27/23

Full 4 weeks

Summer 2024 Oak July 9-25, 2024 (Check all that apply)

Drop in "Put dates in Notes"

Put Dates in "Notes Regarding Enrollment"

Week 1 7/9/23-7/11/23

Week 2 7/25/23-7/27/23

Week 3 7/23/23-7/25/23

Full 3 weeks

We will be paying using: *

Families are responsible for all payments in full beyond what their Charter Funds will cover.

cash or check, please invoice me

credit or debit card, please invoice me

other, please invoice me (please ensure your charter is covering in person classes)

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

MEDICAL AUTHORIZATION *

MEDICAL AUTHORIZATION: In the event that I cannot be reached in an emergency, I hereby give my permission to Wild Oak to administer first aid, and the licensed physician selected by the adult in charge at Wild Oak, Lafayette, CA to examine and treat my child by whatever means necessary. I agree to pay all expenses incurred thereby and I am to be notified at the earliest opportunity. This authorization remains in effect unless revoked in writing delivered to the Wild Oak, Lafayette, CA. Please indicate any factors or conditions that your child’s teacher, doctor or dentist should be aware of in providing any emergency medical or dental treatment. Cite under "Allergies and Conditions" details of any medical conditions or life threatening allergies or conditions of which you are aware, such as insect stings or reactions to medications.

I Consent to the following On-Site Treatment for my Student *

Epipen

Benadryl

Arnica

Essential Oils

First Aid

CPR

Transport off-site with staff and/or emergency services

Waivers *

Please read in full the Terms & Conditions for each Waiver. The Waivers can be found under the Waiver tab. Forest Play: Wild Oak Forest: COVID-19:

Forest Play: I have read and agree to the Terms & Conditions.

Wild Oak Forest: I have read and agree to the Terms & Conditions.

COVID 19: I have read and agree to the Terms & Conditions.

Electronic Signature

By typing your name in the box below, you are signing on behalf of your family and/or household, in acknowledgement that the information provided in this request is true and correct, that you have read and understand and agree to all of the rules, terms and conditions surrounding this agreement, and further understand that failure to comply will result in dismissal from any and all participation in Wild Oak Forest.

First Name

Last Name

Date

MM

DD

YYYY