Summer Program Drop-In Registration Form - Wild Roots Holistic Learning Center

Summer Program at Wild Roots

Wild Roots Summer Program Registration Form
For children ages 2-6 and Grades 1-5; child must be fully potty-trained in order to participate.

Request drop-in for any date(s) from June 17-August 2.
Available days for primary age (2-6):
M, T, W, Th, F from 9 AM - 3 PM
Available days for elementary (Grades 1-5):
Th, F from 9 AM - 3 PM

We currently have drop-in availability in our Primary and Elementary classrooms for our summer program. To sign-up, please fill out the form below and include requested dates at the end of the form. We will confirm our availability for your selected dates via email. Please note that submission of this form does not guarantee registration or availability of your requested dates.

FEES:
M-F Block: $275 per week (available for primary only)
Th-F Block: $125 per week
Daily Fee: $75

Total fees due for selected dates will be sent via email upon confirmation of request.

Child's Full Name *

Birthdate *

Age

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

Please list all dates that you are requesting; Available dates from June 17-August 2.

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

Please read through this thoroughly. This contract is made between {name-2} and Wild Roots Holistic Learning Center. Inc. for the care for {name-1}.

Wild Roots Holistic Learning Center, Inc. is licensed under the California Department of Social Services to provide education and care for up to 120 children. For this purpose, “childcare” means non-medical care for children who are in need of age-appropriate activities, education, and supervision. We currently offer care and supervision for children aged 6 weeks through 12 years under title 22 provision (101169).

Release and Hold Harmless Authorization for Minor
My child’s participation in activities at Wild Roots Holistic Learning Center, Inc. is with the understanding that there are risks of harm or personal injury in any activity involving children and animals; we hereby release, acquit, discharge, and hold harmless Wild Roots Holistic Learning Center, Inc. against any liability resulting from any injury that may occur to my child while participating in childcare activities.

Jurisdiction/ Venue/ Attorney’s Fees
This contract is to be construed under the laws of the State of California. The parties agree to the jurisdiction and venue of the State of California, County of Riverside. Should action be brought to enforce or interpret the provision of the Contract, the prevailing party shall be entitled to attorney’s fees in addition to whatever other relief is granted.

The person(s) executing this contract on behalf of the child are hereby representing that they have the legal authority to do so. By signing this document, each party has read and considered the above terms and conditions, and legally promises and agrees to all stated here or attached hereto.

Other Terms
State childcare licensing regulations are on file at the center and are available for review upon request. Certain state childcare licensing regulations have requirements in addition to those contained in this Agreement. Title 22 Regulations may also be found at www.ccld.ca.gov. In certain circumstances, it may be necessary to discontinue a child’s enrollment. This decision is based primarily on the best interest of the child concerned, the fit of their classroom environment, and the well-being of other students and staff members. Every effort will be made to provide intervention and/or correct the situation before a final decision is made.

Disenrollment from the program without refund to any fees paid may result from (but is not limited to) any of the following circumstances:
• Abuse of other children, staff, or property by child and or parent/guardian
• Continued violation of policies by child or parent/guardian
• Disruptive or dangerous behavior by child or parent/guardian
• The school’s inability to meet the child’s need or the parent/guardian expectation
• Non-payment of fees

This is a partial list, and we reserve the right to end enrollment of a child at any time for any reason deemed appropriate. Whenever possible, prior notification will be provided to the parent.