Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Parent / Legal Guardian Name *FirstLastSecond Parent Name (if applicable) *FirstLastEmail *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePhone (Cell) (parent / legal guardian) *Phone (Cell) (parent 2) ~ if applicablePhone (Home) ~ if applicableName & Age of Child Holiday BREAK *Thursday January 2nd 9:00am-3:30pm - $56.50Friday January 3rd 9:00am-3:30pm - $56.50Saturday January 4th 9:00am-3:30pm - $56.50If registering more then one child fill out new for per child.Please share a little bit about your little one and what their personality is like! 🙂Please share any allergies and all additional health conditions/concerns or medical history related to your child that would be important for us to know.Pay by Credit CardOR E-TRANSFER PAYMENT OPTIONCheck this box to confirm that you will send an e-transfer for the total shown below upon registering & submitting this form.Email: lovechild.breathe@gmail.com (we have auto-deposit enabled) **IMPORTANT**: In the notes of the e-transfer please specify your children's name and specific program (Ex: Little Seedling).Total$0.00Consent & Waiver Information (mandatory to read)I understand that, Love Child Connected does not assume responsibility for any injuries or accidents sustained during participants attendance in the wellness studio. I am aware that this practice is safe but there is an element of risk. While Love child connected participants and facilitators take reasonable precautions to minimize these risks, this is no guarantee against injury or loss. Some of the risks associated with these types of activities include (but are not limited to): scrapes, cuts or bruises; sprains, strains or possible broken bones; illness from known or unknown sources; theft or loss of possessions; and unforeseen injuries from activities, equipment or actions of your child, other participants or other people, including negligent actions. Although it is unlikely, the potential also exists for debilitating injury, long-term incapacity and death.Your child will be following Love child connected Safe and well-being guide which outlines safety management practices. You are welcome and encouraged to review this document. A copy of safe and well-being guide is available from www.lovechildconnected.ca.Participants are expected to conduct themselves in a safe manner and to abide by the Love Child Connected safe and well-being guide. Anyone who does not or whose actions jeopardize their safety or the safety of the group will be dealt with immediately. If appropriate, participant may be sent home at the expense of parents/guardians.I understand that Love Child Connected Wellness Studio for Kids and website are not an attempt to practise medicine or give specific medical advice. The information and programs/activities and games are for the sole purpose of being informative and is not to be considered a substitute of professional medical advice of anyone(s) diagnosis, or treatment. Always seek the advice of your professional or qualified mental health provider with any concerns you may have regarding anyone(s) condition or/and if you believe you or another individual is suffering a mental health crisis or medical emergency seek medical attention immediately or dial 911.Please read the above consent form.Checking this box indicated that I have read and agree to the above Consent and Waiver information/form and have signed below to verify that.Pleaese Sign / type your Full NameWould you like to be added to our newsletter/upcoming classes events and coupons?Yes, pleaseNo, ThanksSubmit & Register