Enrollment – Bumblebees Forest School

Patient Intake Form (#3)

First Name

Last Name

Child's Birthday

Prefered Name / Nickname

Child's Gender

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Child Lives With

Mother

Father

Both

Other

Mother's Name

Mother's Address (If Different Than Child)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone no.

Email Address

Occupation

Father's Name

Father's Address (If Different Than Child)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone no.

Email Address

Occupation

Emergency Contact 1 (include Name, Number, and Relationship to child)

Emergency Contact 2 (include Name, Number, and Relationship to child)

Emergency Contact 3 (include Name, Number, and Relationship to child)

Does your child have any allergies?

Yes

If Yes, Please Explain

Does your child have any other medical condition that may affect their participation in an outdoor school

Yes

If Yes, Please Explain

Does your child have any dietary preferences?

Please list any medications your child would need to take while at school:

Phone Number of primary care doctor:

Allergic to any medications?

Yes

allergic to any medications

1: I/WE HEREBY AGREE AND CONSENT TO THE FOLLOWING: 1. PARENTAL/LEGAL GUARDIAN AUTHORIZATION SIGNATURE FORM FOR MEDICAL TREATMENT In the unlikely event that a serious emergency arises it may become necessary for a physician to attend to your child before the staff can contact you. Your SIGNATURE ON THE AUTHORIZATION FOR MEDICAL TREATMENT FORM is needed to ensure that proper emergency care is provided. This authorization must be signed in order for your child to attend Bumble Bee's Forest School programs. I hereby authorize Bumble Bee's Forest School to provide first aid, including care rendered through the facilities of the nearest physician or hospital for any emergency that may arise while he/she is in attendance at school. I will assume full financial responsibility for all medical, nursing, or surgical care, including transportation of my child. I have carefully reviewed the health procedures information. The information I have provided on this enrollment form is accurate to the best of my knowledge. PLEASE SIGN NAME BELOW

2. MEDIA CONSENT FORM AND RELEASE FOR MINOR CHILDREN I am the parent/guardian of: I hereby grant Bumble Bee's Forest School LLC, an Arizona limited liability company and their agents and employees the absolute right and permission to use photographic portraits, pictures, digital images or videotapes of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any Bumble Bee's Forest School publication, website, social media page, or other advertisement, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied. However, I reserve the right to request the removal of My Child’s likeness from any website, social media, or other digital reproduction from Bumble Bee's Forest School at any time and Bumble Bee's Forest School hereby agrees to honor any such request within 48 hours. I hereby release, discharge, and agree to indemnify and hold harmless Bumble Bee's Forest School and its employees and agents from all claims, demands, and causes of action that I or My Child have or may have by reason of this authorization or use of My Child’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. I represent that I am at least eighteen (18) years of age and am fully competent to sign this Release. THIS IS A RELEASE OF LEGAL RIGHTS. READ IT CAREFULLY AND MAKE SURE THAT YOU UNDERSTAND IT PRIOR TO SIGNING. SIGNING BELOW WILL SIGNIFY BINDING CONSENT WITHOUT RESERVATION ON BEHALF OF YOUR CHILD. (PLEASE SIGN YOUR NAME BELOW)

OPT In

OPT Out

3. FINANCIAL AGREEMENT I/We hereby agree to make tuition payments, monthly and in advance, by the first of each month. I/We agree to pay a 10% late fee if payment is not made by the 7th day of the month. I/We acknowledge and accept that there are no refunds or credits for temporary absences due to personal vacation, school vacations, illness, dismissal and withdrawal. I/We agree to be financially responsible for the payment of all tuition and late fees, and acknowledge and accept that no exceptions will be made. I/We understand the Entrance Fee is non-refundable. (PLEASE SIGN YOUR NAME BELOW)

Todays Date / Time

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1-928-224-5990

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