Cedarvale Ravine Summer Registration Form Additional

Child's Name *

First

Last

Child's Date of Birth *

Child's Age *

Preferred pronoun

She / Her
He / Him
They / Them
Prefer Not To Say

How did you hear about us?

From a friend
Social Media
Newsletter
Word on the street
I was referred by another organization
Google
Other

Please choose your program(s) below *

June 24th - June 28th 9am-12pm (Ages 4-10)
July 1st - July 5th 9am-3pm (Ages 4-10)
July 8th - July 12th 10am-12pm (Caregiver/child)
July 8th - July 12th 1pm - 4pm (Ages 4-10)
July 15th - July 19th 9am-3pm (Ages 4-10)
July 22nd - July 26th 9am-3pm (Ages 4-10))
July 29th - August 2nd 9am-3pm (Ages 4-10)
August 6th - August 9th 10am-12pm (Caregiver/child) (4 days)
August 6th - August 9th 1pm-4pm (Ages 4-10) (4 day)
August 12th - August 16th 9am-3pm (Ages 4-10)
August 19th - August 23rd 9am-3pm (Ages 4-10)
August 26th - August 30th 9am-3pm (Ages 4-10)

Before & After

Before Care - 8am-9am ($40/week)
After Care - 3pm-4pm ($40/week)

DROP IN - Please list the days that you would like to join.

Parent/Guardian Information *

First

Last

Preferred pronoun

She / Her
He / Him
They / Them
Prefer Not To Say

Email *

Phone number *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/Guardian 2 Information

First

Last

Preferred pronoun

She / Her
He / Him
They / Them
Prefer Not To Say

Phone number

Emergency Contact Name *

First

Last

Phone number *

Relationship to Child

Approved Names for Pickup (please separate names with a comma)

Does your child have any food, medication or environmental allergies *

Please list and explain any allergies

Does your child's allergy require an Epi Pen *

Does your child have a special health or medical condition? *

Please explain here any special health or medical condition.

Please provide any additional information about your child that would be useful for Roots 2 Rise staff to be able to best support your child's needs (i.e. emotional, cognitive, behavioural, physical, etc.)

Additional Supports *

I would like to learn more about using my OAP funding and I consent for Roots 2 Rise Outdoors to share my information with KMBC
I do not have OAP funding, however I would like to learn more about the supports available. I consent for Roots 2 Rise Outdoors to share my information with KMBC.
Not applicable

Name *

First

Last

Email *

Date / Time