Registration

Swan Lake Nature Sanctuary Account Form

This account allows you to manage your membership, donations, and volunteerism online.
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First Name: Last Name: Preferred pronouns Email: Phone: Address: City: Province: Postal Code: -

Participating Child's Information

Child's Full Name Child's preferred name Child's Birthday

Pronouns Has your child attended one of our programs before?

Yes

Emergency Contacts & Authorized Individuals for Pick Up

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

Medical Information

If yes, please explain: Please provide details about your child's anaphylaxis, including the date and description of the reaction: Will your child be taking any medications while at the program?

Supports for Child Participant

Does your child have any restrictions on activity? Will your child require any special assistance while at the program? Other:

Permissions

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 Sanctuaryshould there be any change in my child’s health prior to the start of the program or during the program.

I agree

In case of emergency, please provide your child's Personal Health Identificiation (PHI): 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.