Chava Farms Summer Registration Additional

Child's Name *

First

Last

Child's Date of Birth *

Child's Age *

How did you hear about us?

From a friend
Social Media
Word on the street
Google Search
Referral from an organization
Other

First Preferred pronoun

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

Please choose your program(s) below *

August 6th - August 9th (4 Days)
August 12th - August 16th
August 19th - August 23rd

Before and After care

Before Care (8am-9pm) $40/week
After Care (4pm-5pm) $40/Week

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

Parent/Guardian Information *

First

Last

Preferred pronoun

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

Email *

Phone *

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

Emergency Contact Name *

First

Last

Phone

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 Support *

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

Code