Thanks for your interest in our Connections Program for foster and adopted children. We look forward to helping your children thrive!

ONE DAY PROGRAM

June 22, 9 am - 1 pm

Ages 5 - 11

Charlotte’s Quest Nature Center, 3400 Wilhelm Lane, Manchester, MD

This inaugural one day program will give families a taste of what Connections programs are all about. Group activities and games not only provide fun, but will be aimed at building healthy connections.

Please fill out the registration form below. Once registered, you will receive an email with more details and information prior to the day of the program.

Parent/Caregiver Name

First Name

Last Name

#1 Child's Name

First Name

Last Name

#2 Child's Name

First Name

Last Name

#3 Child's Name

First Name

Last Name

Child/ren's Birthdate

Please list birthdates and ages for all participants

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact Person/Relationship

Does your child have any medical conditions or issues we should know about?

Please describe for each child as necessary

Does your child have any allergies? If so, what are they?

List for each child

Name of Health Insurance Carrier

Name for each child, if different

Insurance ID number

List for each child, if different

Family Doctor or Pediatrician Name/Phone #

Is your child/ren current with their immunizations

Answer for each child

CONSENT FOR MEDICAL TREATMENT

In the event that I cannot be reached in an emergency requiring medical attention for the above named child, permission is hereby given for the staff of Skipping Stones whom are CPR/first aide certified to administer CPR and/or first aid as deemed necessary. Further permission is given to allow medical services to be performed by doctors, hospitals or other qualified medical providers as deemed necessary in an emergency, including surgery if reasonably necessary. I understand that the cost of all emergency services is may responsibility. *

Signature of Parent/Guardian/Date

PHOTO RELEASE

Occasionally photos will be taken during program and will be used for Skipping Stones publications including its website and Facebook page. However, we will not identify your child by name or release any personal information

Please note if photo permission is different for any of your children

LIABILITY RELEASE WAIVER AND AUTHORIZATION

Participation at a Skipping Stones location exposes participants to certain risks of being in the outdoors. Accidents and injuries resulting from the forces of mother nature, live animal and bug interactions, slipping and falling, malfunctioning equipment, unseen obstacles, fatigue, and your own and others' misjudgment are very real possibilities. Affirmation and Liability Release: THE UNDERSIGNED CERTIFY THAT THEY AGREE AS FOLLOWS: 1. I hereby affirm that I have been informed that there are inherent dangers of being outdoors at a nature program. 2. While all program participants are consistently well supervised, accident do happen. The undersigned(s) assume(s) all risk of injury or harm to the child associated with participation in the program and agree(s) to release, indemnify, defend and forever discharge Skipping Stones and it's staff, employees, and agents of and from al liability, claims, demands, damages, costs, expenses, actions and causes of action in respect of death, injury loss or damage to the child, or by the child, howsoever caused, arising or to arise by reason of or during the child's participation in the program. 2. I hereby agree to heed at all times the advice and instructions of Skipping Stones and its owners to practice common sense while at the program. 4. The above named participant, a minor child has permission to participate in the activities of Skipping Stones programming. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child's participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against Connections and Skipping Stones, LLC on the basis of any claim from which I

Parent/Guardian Signature/Date

Thank You!

We look forward to making CONNECTIONS with you and your child/ren!