Child's Legal Name
*
Please write your child's name as it appears on legal documents
First Name
Last Name
Child's Nickname or Preferred Name
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If your child has a nickname or preferred name other than what appears on their legal documents please include that in the line below. If this section does not apply please write N/A in the box below
First Name
Last Name
Child's Date of Birth
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1. Parent/Guardian 1
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First Name
Last Name
Parent/Guardian 1 Pronouns
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Parent/Guardian 1 Email
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Parent/Guardian 1 Phone
*
(###)
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2. Parent/Guardian 2
First Name
Last Name
Parent/Guardian 2 Pronouns
Parent/Guardian 2 Email
Parent/Guardian 2 Phone
(###)
###
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Emergency Contact (other than parent/guardian)
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Please include an emergency contact other than parent/guardian.
First Name
Last Name
Phone Number for Emergency Contact
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Must be different from parent/guardian phone numbers
(###)
###
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Name of Child's Physician
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First Name
Last Name
Phone Number for Child's Physician
*
(###)
###
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Please list any allergies (food or environmental) or medical conditions your child has. If none, write 'none.'
*
Consent for Medical Treatment
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In the case of a medical emergency, I understand that every reasonable attempt will be made to contact the Parent(s)/Guardian(s) or another designated emergency contact. However, in the event that I cannot be reached, I give my permission to the Educators of Brooklyn Nature Days, LLC to help my Child and secure emergency medical treatment. I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance. This acknowledgement and consent applies for the duration in which my child attends class.
We want to support all children in our care. Does your child have an iep, see an OT/PT, or have any other intellectual/emotional/physical needs that you would like for us to be aware of?
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If none please write 'none'.
Acknowledgement of Risk
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I acknowledge that there are risks inherent in any youth activity, including – but not limited to – injury arising from participation in outdoor physical activity. I acknowledge that all risks cannot be prevented, and assume those beyond the reasonable control of the teachers and staff. In consideration of being permitted to participate in Brooklyn Nature Days, LLC, on behalf of myself, my family, my heirs, and my assigns, I hereby release and hold harmless Brooklyn Nature Days, LLC, its teachers and its staff from any liability for injury, loss, or death to the Child. In order to minimize risks to my Child and others, I will take responsibility to make sure that my Child is prepared for all activities, dressed appropriately for the weather, and is in good health for each class. I am also aware that Prospect Park is a public park with rough terrain and wild animals, and open to the general public for various activities. I appreciate and accept that risk and waive any right to pursue legal remedies associated with inherent risks of the park.
COVID-19 Acknowledgement of Risk
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Parents may have reservations about having their child participate in an in-person program due to the potential risks associated with the current COVID-19 pandemic. Although Brooklyn Nature Days, LLC (“BND”) will comply with the guidance provided by the New York State Department of Health, BND cannot eliminate the risk of exposure or spread of COVID-19 during the in-person program. By allowing your child to participate in the in-person program operated by BND, you understand and accept these potential risks.
Sunscreen & Bugspray Acknowledgement
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Children should arrive in the mornings wearing sunscreen & bugspray. Teachers will check in with caregivers that they have applied sunscreen and/or bug spray on their child. If the answer is no, the caregiver will be asked to apply before checking the child in. Reapplication of sunscreen and bugspray is required during class. Each child needs to bring their own sunscreen and bugspray to class each day. Children must reapply their own sunscreen or families should send additional sun protecting clothing to be worn as needed throughout the day. Children must apply their own sunscreen per NY State law, however teachers may assist a child in applying bugspray as needed. If you do not wish for your child to reapply their sunscreen/bugspray please reach out to us in writing via brighthwheel.
Outdoor toileting affirmation and release
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Media Release
If you do not want photographs and video clips of your child to be used on the Educator's websites and promotional materials please choose nothing in this section.
Schedule, Tuition, and Payment
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Tuition is non refundable, non transferable and due in full prior to your child attending class.
By enrolling in our classes, families assume responsibility for the full balance due. Families are responsible for the full balance due, regardless of the days their child actually attends. No refunds or credits given for classes missed, including those due to travel, illness, or schedule conflicts.
Signature
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By signing this form electronically, I attest I am the parent/guardian of the above child and I am the person whose name appears in the box below. I have reviewed this document, as well as BND’s COVID Safety Procedures and Protocol, and have elected to have my child participate in an in-person program at BND during the 2022-2023 school year.
First Name
Last Name
Today's Date
*
Email of Parent/Guardian Signing Form
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Mailing Address
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Please enter your permanent mailing address.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
