Select Class
Young Infant (2 mo. - 7 mo.)
Older Infant (5 mo. - 11 mo.)
Young Toddlers (14 mo. - 24 mo.)
Older Toddlers (24 mo. - 32 mo.)
Name
*
First Name
Last Name
Email
*
Phone
(###)
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Child's Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
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Child's Birthday
*
MM
DD
YYYY
Does your child have any medical or allergies I should be aware of?
*
Who will be attending class with your child?
*
Relationship to Child
*
Tell me about your child. Tempermament, mobility, likes/dislikes, daily routine
*
Does your child have any siblings? If yes, what are their ages?
*
Is there any other information I should know?
How did you hear about us?
Release of Liability
*
I, and/or my minor child (collectively, whether one or more, “We”) hereby give permission to participate in the Nurtured Community Group Classes provided by Samantha Deal, and we hereby release and hold harmless all employees and volunteers associated with Nurtured Community from any and all liability and claims which may arise from my and my child's participation in the Nurtured Community Group classes.
Photo Consent
*
I grant Nurtured Community and it's authorized representatives permission to photograph my child’s participation in the Nurtured Community Group Classes. Occasionally, we may take audio recordings, photographs, or videos of the children participating in our classes. These materials may be used for educational, training, and promotional purposes. By agreeing to allow your child's photograph to be taken, you consent to your inclusion in these materials. No names of children or parents will be used without additional consent.
