WILD HEARTS ADVENTURE CO. ENROLLMENT FORM Please enable JavaScript in your browser to complete this form. - Step 1 of 5Learner's InformationLearner's Name *Preferred NameDate of Birth *Grade *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent/Guardian Name *Phone Number *Email *Alt. Phone NumberEmergency Contact NameRelationship *ParentGrandparentAunt/UncleSiblingOther FamilyFriendPhone NumberNextAdditional InformationIs your child enrolled in a charter school at this time? *YesNoCharter School *Choose one...Heartland Charter SchoolMonarch RiverYosemite ValleyERCLCOtherName of Charter SchoolWill you be using funds from this school to pay tuition? *YesNoPlease be advised that Heartland Charter School limits the attendance of its learners at Wild Hearts Adventure Co. to no more than 2 days/wk under any circumstances, and using any method of payment. If you have any questions about this, please reach out to your HST. Program Attendance *MondayTuesdayWednesdayThursdayFriday MakerspaceHalf-Time Makerspace (2 wks/mo)Please choose all this learner plans to attendWhich 2 Fridays do you plan to attend? *1st Friday of the month2nd Friday of the month3rd Friday of the month4th Friday of the monthDigital options (ie. Minecraft STEM) will only be available (with parental consent) the 1st and 3rd Fridays. Woodworking will only be available the 2nd and 4th Fridays. Traditional makerspace options (ie. art, crafting, etc) will be available all weeks.Are you attending full-time M/W, or our Charter Flex Progam (3 wks/mo only) *Full-Time M/WCharter FlexPlease choose all this learner plans to attendAre there any traditional holidays, celebrations, etc., that your family is opposed to participating in? *YesNoPlease explain further: *Does the learner have any allergies or food restrictions? *YesNoPlease tell us more about the allergy/ies. What type of reaction do they have (if any)? (ie. itching, swelling, behavior changes, intestinal distress, anaphylaxis, etc.) *Does the learner have any other medical issues or learning/social differences that we should be aware of? *YesNoPlease explain further: *What are your primary goals for your child’s time at Wild Hearts? (General or specific education support, social opportunities, etc.) What are some of the learner’s talents and special interests?Program Policy AgreementsCOMMITMENT Parent may withdraw the Student from the program at any time, for any reason, with thirty (30) days' written notice. Notice may be given through withdrawal form submission only. Text message, email, social media message, verbal notice, etc. is not accepted. Parent will remain responsible for any tuition amounts due prior to and during the thirty (30) day period regardless of Student attendance. Commitment *I understand and agreeI do not agreePAYMENTS Tuition is annual and may be paid annually or split into 9 monthly payments to be billed from September through May. Parents are charged the annual or monthly payment fee regardless of Student attendance. As such, no credits, discounts, makeup days, or refunds are provided for sick days, vacation days, calendar holidays, professional development days, half-days, or other missed days. Monthly tuition is due on the last day of the month prior to the month of attendance. If payments are not received by the 5th of the month, a $30 late fee will be added to the invoice. (Does not apply to payments from charter school certificates) Families are allowed one (1) month of suspended attendance to provide the flexibility for extended vacations or other personal family needs. Monthly invoice will still be received, but tuition amount will be reduced to $0. Requests must be submitted in writing (email or request form submission only), on or before the last day of the month prior to the month being requested off. Payments *I understand and agreeI do not agreeSUSPENSION AND TERMINATION We reserve the right to suspend or terminate any student from the program, at our sole discretion. Some reasons a student may be discharged include misconduct, inappropriate behavior by either the student or a family member, any behavior by either the student or family that violates any Wild Hearts Adventure Co. policy, and non-payment. Should a student be involuntarily discharged or expelled from the program, the family forfeits all payments for tuition. Suspension and Termination *I understand and agreeI do not agreeAGREEMENT By signing below, Parent acknowledges that this Agreement is between Wild Hearts Adventure Co. and the undersigned Parent to enroll Student at Wild Hearts Adventure Co. Signature * Clear Signature Date *NextRelease of Liability Student Name *Parent/Guardian Name *By signing below, Parent represents and acknowledges that Parent is the parent or legal guardian of the student identified above (“Student”) with legal authority to agree to the terms and conditions of this Authorization. Parent consents to the Student’s participation in the program operated by Wild Hearts Adventure Co., including their attendance at Program. Parent forever releases, acquits, discharges, and covenants to hold harmless Wild Hearts Adventure Co. and its agents, employees, officers, directors, successors, and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses, and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which Parent may now have or may hereafter have that result from or relate to the Student’s participation in the Program or engagement in related activities unless such injury, loss, or damage is due to the gross negligence of Wild Hearts Adventure Co. “Related activities” include but are not limited to activities sponsored by, carried out by, or otherwise involving Program or a related third-party, such as after-hour or weekend program events, field trips, excursions, and community service activities. Notwithstanding anything contained in this Authorization to the contrary, no personal liability shall accrue against any individual officer, director, member, partner, fiduciary, employee, agent or representative of Wild Hearts Adventure Co., or any heir, personal representative, successor or assign of the foregoing with respect to any matters arising under this Authorization. Parent assumes liability for and shall indemnify and hold harmless Wild Hearts Adventure Co. from and against any and all losses, damages, penalties, liabilities, claims, actions, suits, costs, and expenses, including reasonable attorney’s fees, whether in law or in equity, of any kind or nature whatsoever, imposed upon, incurred by, or asserted against Wild Hearts Adventure Co. in any way directly or indirectly relating to or arising out of any negligent or other wrongful act or omission of the Student. The provisions of this paragraph shall survive the termination of Student’s participation in the Program. In signing this Authorization, Parent acknowledges and represents that Parent has read the foregoing Authorization, understands it, and signs it voluntarily. Parent executes this Authorization for full, adequate, and complete consideration. Parent understands that Parent is permanently giving up the right to sue. Parent hereby asserts that participation is voluntary and that Parent knowingly assumes all risks. Parent has carefully read this agreement, has carefully considered it, and attests that Parent fully understands and knowingly and voluntarily accepts its terms in their entirety and without reservation, including the release of all known and unknown claims. Signature * Clear Signature Date *NextMedical Emergency I, *Parent/Guardian Nameon behalf of my child, *Child's Nameauthorize the staff of Wild Hearts Adventure Co. who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached and a delay would be dangerous to the health of my child, I hereby authorize the program to transport my child to a medical care facility and to secure necessary medical treatment for my child. Signature * Clear Signature Date *NextMedia ReleaseI hereby give my consent for photographs, audio recordings, academic work, and/or video recordings taken of my minor child(ren) by Wild Hearts Adventure Co. staff or designee, during the course of classes or other Wild Hearts Adventure Co. events, to be used to share in social media posting and for other promotional purposes to be determined by Wild Hearts Adventure Co. Media Consent *Yes, I give my consent.No, I do not give my consent.Parent/Guardian Signature * Clear Signature Date *PreviousSubmit