Learning Outside - Acceptiva

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Forest Kindergarten

Ages 3 – 6

Monday through Friday

8:45 - 12:45

Tuesday, September 3 - Friday, May 30

OUR PAYMENT PLAN

Forest Kindergarten - 5 Days *priority is given to youngsters enrolling for 5-days*

$996.98

Forest Kindergarten - 4 Days

$797.58

Forest Kindergarten - 3 days

$598.19

Choose A Frequency

Recurring Frequency:

You will be charged your first installment payment today.
Remaining installments will be charged monthly beginning Sept 4th,
regardless of the date listed on the receipt that you receive for today's payment.

(5% transaction fee applies to payment plan)

Qty

Description

Amount

Total

Supplies & Administrative Fee

$150.00

Would you like to Round Up?

Round Up to make a donation and help Learning Outside impact more children!

Round Up Donation

Total: $150.00

Please select the days you would like your child to attend:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Registrant Information

A complete and accurate registration provides safety for your child. It is the information we rely on in an emergency.

Child's First Name: *

Child's Last Name: *

Preferred name to be used:

Gender: *

Date of Birth: *

Age: *

(At start of session in September)

Home Address: *

City: *

County: *

State: *

Zip Code: *

Parent/Guardian #1/Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card or bank statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Work Phone: *

Cell Phone: *

Home Phone: *

E-mail: *

A receipt will be e-mailed to this address.

Parent/Guardian #2 Information

Name:

Address:

Address 2:

City:

State:

Zip Code:

Work Phone:

Cell Phone:

Home Phone:

Email:

Emergency Information
EMERGENCY contact person (if parent/guardian cannot be reached)

Name: *

Relationship To Participant: *

Home Phone: *

Work Phone: *

Cell Phone: *

BACKUP CONTACT PERSON (in case primary contact cannot be reached):

Name:

Relationship To Participant:

Home Phone:

Work Phone:

Cell Phone:

Medical Contact Information

Name of Doctor:

Office Phone:

Office Address:

Name of Dentist:

Office Phone:

Office Address:

Health Information

Health Insurance Company: *

Policy Number: *

Participant’s Allergies & Allergy Management: *

(food, drugs, insects, plants, etc. and guidance on how their allergy is managed/treated or N/A)

List all medications & medical conditions: *

(Please include any childhood illnesses. If none, enter N/A)

Does your child, or has your child ever, worked with a Therapist, Early Childhood Specialist or other support person? (Ex: Occupational Therapist, Phsyical Therapist, Speech/Language Therapist, Play Therapist, Family Therapist, Psychologist)

If yes, please share details here: *

(If not, enter N/A)

Hospitalized and/or any surgeries in last year? *

Has the participant been hospitalized and/or had any surgeries in the last year?

Chronic Medical Conditions? *

Does the participant have any chronic medical conditions that require him/her to be under the care of a doctor? (Epilepsy, Asthma, Diabetes, Heart Condition etc.?)

If yes, please explain:

Date of most recent tetanus, DTP, DTaP shot? *

NC Immunization
Exemption Form:

Check here if you are submitting a NC Immunization Exemption Form.

Are there any challenges, handicaps, fears: *

If yes, please describe:

Special Dietary Restrictions:

Other Important Information

Does your child currently attend another program/school? *

If so, please share which one, something about the program and how it's going, or if transferring out of it, please share why.

What do you hope your child will gain from being in an outdoor setting such as ours? *

Will your child be attending another school or program in addition to Forest Kindergarten? *

If so, which one, and what are the gifts you hope your child will gain from this other school or program? If not, enter N/A

What is challenging for you about your child's behavior and individual needs? *

What is fun and easy for you with regard to your child's personality? *

What is something you would like for us to know or think that we should know about your child? *

What is your family's approach to behavior management and conflict resolution? *

What is your family's philosophy in regards to screen time? *

What is your family's TV, videos (movies, YouTube videos, etc.), videogame, iPad/phone/computer philosophy and how much screen time does your child spend? What kind of shows/movies or games do they watch or play?

Does your child have any challenges?

Does your child have any social challenges, communication challenges, physical limitations, handicaps, fears or other conditions that Learning Outside staff should be aware of?

Does your child show signs of struggling with anxiety?

If so, have you been able to identify triggers for their anxiety and/or strategies to help them when they are feeling anxious?

Does your child have a hard time separating from you, and is this a concern for you? *

Are you comfortable with your child getting muddy and dirty? *

(Please note, your child WILL get dirty and your response to this is important to whether they feel ok with being involved in the play that happens at Learning Outside.)

Release Statement and Agreement

Release Statement
I hereby attest that all of the information provided above is correct and complete.

In event of injury or illness, I give the Learning Outside Staff and emergency/professional medical personnel permission to provide medical treatment for the participant listed above.

Release Statement: *

I have read the above and give permission.

Hold Harmless Agreement
Learning Outside offers outdoor learning programs on Triangle Land Conservancy’s Irvin Nature Preserve, 269 acres of pasture, forest and wetlands preserved in perpetuity by the Triangle Land Conservancy in Orange County. Program activities include art, science and other learning activities for both children and adults.

Activities in this program may include, but are not limited to: gardening, farm chores, interaction with goats, chickens and other farm animals as well as cats and/or dogs, drawing, painting, printmaking, other arts and crafts activities, nature crafts, singing, song writing, storytelling, dance, creative drama, puppet making, nature exploration, shelter building from natural materials, fire building, cooking, animal tracking, running games and other strenuous physical activity, archery, walking along the farm driveway to the pond, pond exploration and wading in the pond, hikes in the woods and to the creek, creek exploration and wading in the creek, work with woodworking hand tools and more.

Risks inherent in these activities include, but are not limited to:

Exposure to biting insects, ticks, poison ivy, and poisonous snakes
Exposure to diseases carried by ticks and other biting insects
Walking, hiking, running and playing in hot or otherwise inclement weather
Falls from climbing or slipping on pond banks, tree stumps, branches, & uneven terrain or tripping on rocks/stumps
Injuries from use of sharp tools for carving, whittling, gardening and/or woodworking, or glue guns and allergic reaction from exposure to paints, paper mâché paste, cement, and other art materials during arts and crafts activities
Burns from hot plate, camp fire, or hot food/liquids during cooking activities
Drowning or injury while wading or playing in natural bodies of water
Accidents on the driveway
Risks normally associated with travel in a car driven by staff, hired driver or parent a participant

I authorize Wendy Banning, Director of Learning Outside, as well as all paid and volunteer instructors in whose care my child has been entrusted, to lead the above named child in activities of the type listed above. I understand that there are risks inherent with the activities as well as with transportation to and from each area. I nevertheless voluntarily assume all risks of loss, damage or injury that may be sustained through my child's participation in programs offered by Learning Outside.

I agree to hold Learning Outside, Wendy Banning and all other instructors, volunteers, staff, independent contractors, hired drivers and Learning Outside Board Members as well as the Triangle Land Conservancy harmless for injuries which may occur during such activities or while being transported to and from such activity.

Hold Harmless Agreement: *

I have read the above and agree to all terms.

Multimedia Image Release
I hereby give permission for my child’s image to be used by Learning Outside and Wendy Banning, Learning Outside’s Director, for outdoor learning presentations, teacher training, publications, advertising and fundraising, including on the Learning Outside websites (www.learningoutside.org + www.learn-outside.com) and the Learning Outside Facebook page or Instagram or the Triangle Land Conservancy website.

NOTE: For security reasons, children’s names are not used with photos in any of these places.

Media Release: *

Learning Outside Policies

The registration and payment receipts are not a guarantee of enrollment. All enrollments will be confirmed by personal email from Learning Outside to the parent/guardian.

I have read the above statement regarding enrollment.

No refunds for withdrawals:

I accept that there are no refunds for withdrawals.

I understand and acknowledge that Learning Outside reserves the right to cancel or postpone any of its programs, events, workshops, or gatherings of any kind scheduled to be held at the site for reasons including, but not limited to, safety concerns, weather, and community health risks without reimbursement for any session(s) missed.

I have read the above statement and accept this policy

No make up days for sessions missed due to weather or illness:

I accept that there are no weather make-up days or make up days for absences due to illness.

Race/Ethnicity

The grants that Learning Outside applies for each year require that we specify the racial and ethnic backgrounds of the children enrolled in our programs. Please check all that apply.

Black

African American

Hispanic or Latino

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaskan Native

White

Multi-Racial

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *