Learner Details Form – Wild Hearts Adventure Co

Learner's Information

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Learner's Name *

Preferred Name

Date of Birth *

Grade *

Address *

Address Line 1

City

State

Zip Code

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Parent/Guardian Name *

Phone Number *

Email *

Alt. Phone Number

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Emergency Contact Name

Relationship *

Phone Number

Charter School Information

(If your learner is not enrolled with a charter school, please click "No" and proceed to the next step.)

Is this learner enrolled in a Charter School? (If attending Makerspace Friday ONLY please check NO) *

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Charter School

Name of HST/IST

Wild Hearts Adventure Co. will support Heartland Charter students in producing one state-standard grade level sample in the subject specified by the schedule set by Heartland charter school in each Learning Period. If you wish to be provided with additional samples, or if you’re on a schedule that differs from the one set by Heartland please let us know. *

I have read and understand.

Would you like us to support your learner in creating work samples?

YES, we would like to receive completed work samples.
NO, We don't need work samples.

All families enrolled full-time with Wild Hearts Adventure Co are entitled, upon request, for their learners to be supported in producing 2 grade-level work samples (one each from Science, and Social Studies) each full month they are enrolled and attending Wild Hearts Adventure Co classes. *Learner must be enrolled in the offered applicable classes. (Part-time enrolled families are entitled to 1 grade-level sample; subject to be determined by days in attendance.) Note: Absences may impact work sample availability. *

YES, I am requesting for my learners to be supported in producing grade-level work samples in the following selected subjects. I understand that these samples are to be provided to me, the parent or guardian, and it remains my responsibility to submit these work samples to my charter school if they are to be used to fulfill a charter school requirement.
NO, we do not need work samples to be provided.

Checkboxes *

Science
Social Studies

Additional Information

Are there any traditional holidays, celebrations, etc., that your family is opposed to participating in? *

Please explain further: *

Does the learner have any allergies or food restrictions? *

Please 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? *

Please explain further: *

What are your primary goals for your child’s time at Wild Hearts? (General or specific education support, social opportunities, etc.) - Not required for Makerspace Only

What are some of the learner’s talents and special interests?

Media Release

I 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.

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Parent/Guardian Signature

Date