Heartland Farm Sanctuary Online Registration

Registration

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Welcome to Heartland Farm Sanctuary! Please complete the following form to register in our Humane Education programming! After registering you will be transferred to the parent portal where you will enroll and pay for classes. Thank you!

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Account Name (e.g. family name) Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Primary Contact First Name*

Last Name *

Relationship to Child

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Additional Authorized Pick Ups First Name

Last Name

Type

How can we contact you?

Work #

Cell # *

Student #1

Student's First Name*

Last Name*

Gender Identity

Birth Date*

Additional Info

Does your child have any accessibility needs for camp (such as supports during outdoor activities)?*

Does your child have any other support needs for camp?*

Does your child have any allergies that may affect them during camp? If yes, are any severe?

Please list any medications that your child will be taking during camp hours (leave blank if none):

Photo Release (Yes or No)*

Pronouns (e.g. she/her/hers)

Preferred Name or Nickname

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity

Birth Date*

Additional Info

Does your child have any accessibility needs for camp (such as supports during outdoor activities)?*

Does your child have any other support needs for camp?*

Does your child have any allergies that may affect them during camp? If yes, are any severe?

Please list any medications that your child will be taking during camp hours (leave blank if none):

Photo Release (Yes or No)*

Pronouns (e.g. she/her/hers)

Preferred Name or Nickname

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity

Birth Date*

Additional Info

Does your child have any accessibility needs for camp (such as supports during outdoor activities)?*

Does your child have any other support needs for camp?*

Does your child have any allergies that may affect them during camp? If yes, are any severe?

Please list any medications that your child will be taking during camp hours (leave blank if none):

Photo Release (Yes or No)*

Pronouns (e.g. she/her/hers)

Preferred Name or Nickname

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity

Birth Date*

Additional Info

Does your child have any accessibility needs for camp (such as supports during outdoor activities)?*

Does your child have any other support needs for camp?*

Does your child have any allergies that may affect them during camp? If yes, are any severe?

Please list any medications that your child will be taking during camp hours (leave blank if none):

Photo Release (Yes or No)*

Pronouns (e.g. she/her/hers)

Preferred Name or Nickname

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity

Birth Date*

Additional Info

Does your child have any accessibility needs for camp (such as supports during outdoor activities)?*

Does your child have any other support needs for camp?*

Does your child have any allergies that may affect them during camp? If yes, are any severe?

Please list any medications that your child will be taking during camp hours (leave blank if none):

Photo Release (Yes or No)*

Pronouns (e.g. she/her/hers)

Preferred Name or Nickname

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)