Mini & Me Registration Form - Wild Roots Holistic Learning Center

Mini & Me Winter/Spring Session

Mini & Me Winter/Spring Session
$175 | 6-Week Session
Starts February 20
Tuesdays, 9:30 AM-10:30 AM

Child's Full Name *

Birthdate *

List any allergies and/or special needs. If none, put N/A *

Parent/Guardian 1 Full Name *

Parent/Guardian 1 Email Address *

Parent/Guardian 1 Phone Number *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Country

Parent/Guardian 2 Full Name

Parent/Guardian 2 Email Address

Parent/Guardian 2 Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Media Consent

Publication for Wild Roots Holistic Learning Center, Inc. will regularly take photographs and/or video footage of children engaged in activities. This content will be utilized in creating project documentation, as well for promotional purposes which include but are not limited to marketing materials, web content, social media content including Facebook, Instagram, Twitter, and YouTube. Wild Roots creates content in order to enrich our school community involvement, and to spread the Wild Roots message to like-minded families.

Please select one: *By checking here, you hereby give permission for professional and appropriate photography and/or video footage to be taken of your child and used in any capacity listed above, without the necessity for Wild Roots to obtain specific permission from you for each instance. Your child’s name will not be mentioned or tagged in any content at any time, but his likeness may appear in Wild Roots in-school and/or web content, and/or on Wild Roots social channels periodically. Your child will be included in photos and/or video footage of classroom activity.By checking here, you hereby do not give permission for any photography or video footage to be taken of your child whatsoever. By initialing here, you are ensuring that your child will not under any circumstances be included in Wild Roots in-school or web content, or on Wild Roots social channels at any time for any reason. Your child will not be included in photos or video footage of classroom activity.

Parent Acknowledgements

As the parent/guardian of {name-1} , I agree to supervise my own child’s safety and health needs while at the Parent and Me class. I understand that while Wild Roots will provide a developmentally appropriate environment, the school is not liable or responsible for incidents or injuries while in the Parent and Me class.

I, {name-2} , understand and agree to the payment policy of the Mini & Me class as a 6-week session for $175 which cannot be pro-rated or refunded for any reason, including illnesses, as Wild Roots will plan snacks, activities, and space according to a specific number of families.

Please check to confirm: *

By checking this box, I agree to the statements above

Please choose a payment methodOnline (PayPal, Debit/Credit Card)Cash or Check (Must be made in-person by January 15)