Youth Community Medical

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Medical information is required for your child to attend this program. It is essential to have your child's current health information to be able to ensure the safety and well-being of other students during their time in the program.

This information is collected for the administrative and/or operational functions of Swan Lake Christmas Hill Nature Sanctuary in accordance with the Freedom in Information and Protection of Privacy Act.

Information/Authorization

Please complete one form for each child. This form must be completed one week before class.

Program Name

Program Date(s)

Child's Full Name

Child's Birth Date

Child's Age

Pronouns

Gender Identity

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Phone Email

Parent/Guardian Phone

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Emergency Contacts

Please list at least one other adult than you that is authorized to pick up your child after class. Please note: it is our strict policy to release children from our care ONLY into the direct care of a parent or an adult authorized on this form.

Emergency Contact 1: Name

Emergency Contact 1: Phone

Emergency Contact 1: Relationship to Child

Emergency Contact 2: Name

Emergency Contact 2: Phone

Emergency Contact 2: Relationship to Child

General Information

Has your child attended one of our programs before?

Yes

What does your child want to learn at Swan Lake Christmas Hill Nature Sanctuary?

What is your child's experience in nature education and the outdoors?

Secure Payment

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I hereby give my consent for a Sanctuary staff member to call a medical practitioner or ambulance for my child in the case of accident or illness, if I can not immediately be reached. I agree that the information provided above is a complete and accurate statement. I realize that failure to disclose such information could result in serious harm to my child and/or fellow students. I agree to hold Nature Sanctuary and its staff harmless if all relevant information is not disclosed. I also agree to notify the Nature Sanctuary should there be any change in my child’s health prior to the start of the program or during the program.

I agree

I give permission for my child, named above, to be photographed and/or videotaped by SLCHNS staff which may be used on the website, in print, electronic media, and/or the community newspaper for promotional purposes.

We require 48 hours notice for cancellations. Any cancellation within 48h before class starts or any no-shows are non-refundable. It puts a lot of strain on a small non-profit organization to offer refunds (due to staff time and the cost of issuing e-transfers). We appreciate your understanding.

I understand and agree to the cancellation policy.

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Secure Payment

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We acknowledge that the Nature Sanctuary is on the ancestral territories of the lək'ʷəŋən peoples, represented by the Songhees and Esquimalt Nations, and W̱SÁNEĆ peoples, represented by the W̱JOȽEȽP (Tsartlip), BOḰEĆEN (Pauquachin), SȾÁUTW̱ (Tsawout), W̱SIḴEM (Tseycum) and MÁLEXEȽ (Malahat) Nations. We respect the vital relationships of First Peoples with these lands and waters for countless generations. We are honoured to invite and welcome Indigenous guidance and collaboration in stewardship and appreciation of the Nature Sanctuary.