GUG application & demographic form

Nature School Registration

Please fill out this form to register your child for our program.

Child's First name

Last name

Child's Birthday

Month

Day

Year

Name(s) of Parents/ Legal Guardians

Address

Primary email address

Primary phone number

Additional phone number

Additional email address

Name and Phone Number of Emergency Contact (besides parents)

Names of people (besides parents and emergency contact) authorized to pick up child

Which day(s) are you interested in attending?

Monday Nature School

Tuesday Nature School

Thursday Homeschool

Friday Fun Nights

Physician name and phone number

Health Insurance Carrier & Policy Number

Please provide pertinent information about your child (Interests, likes/dislikes, temperament/personality style, and any other information or concerns you wish to share or you feel is relevant

Health concerns or disabilities

yes

no

If yes, please explain

Allergies, reactions or food restrictions

yes

no

If yes, please explain

Administration of special health, dental, or dietary needs

yes

no

If yes, please explain

Consent given for emergency medical care

yes

no

Consent given to ride in GUG van (with carseat/booster provided by parent)

yes

no

Consent given for photos to be shared with fellow GUG families in our private album

yes

no

Consent given for photos to be used publicly for promotional use or for media publication. Permission is granted for Growing Up Green to utilize images of myself or my child without informing me in advance of each occasion that the photo is used

yes

no

I understand a fee of $1 per minute will be charged if my child is not picked up within 5 minutes of the end of our scheduled pickup time

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date Signed

Month

Day

Year