Virtual Camp Registration Form - Region of Waterloo

Parent's Name*

First Last

Material Shipping Address*

Street Address Address Line 2 City Province Postal Code

Phone Number*

Student's Name*

First Last

Student's Birthday*

Student's Grade*

Select Program(s)*

Does your child have any allergies? If so, please describe

Does your child require any kind of educational support?

Is there anything else you would like us to know about your child?

How did you hear about us?

Photo Consent*

Yes
No

Do you give consent for your child's photo to be taken and used for LMS Social Media and Marketing?

Terms and Conditions*

Select All
This agreement releases Little Medical School - Region of Waterloo, from all liability relating to injuries, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation and enrollment in their programs and on the use of the classroom materials received from them.
I hereby affirm that my child is in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in Little Medical School - Region of Waterloo programs.
The online class will use Zoom. This is a free app you can download or use in a web browser. By default, video is turned on for all participants, which lets the online instructor and other participants see each other. You can turn off your Zoom video using the Zoom controls. If you keep the Zoom video on, the participant(s) may appear in the session recording as small, thumbnail images.
By keeping your Zoom video on, "I grant permission to Little Medical School - Region of Waterloo the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium. I waive my right to any compensation."
I agree that I shall not record or distribute any part of the presentation or Zoom class – may it be audio, video, still photography as the contents of the presentation are subject to copyright laws.

Waiver of Liability and Use of Zoom

Refund and Cancellation Policy*

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The parent agrees to provide 7 days written notice prior to terminating a child from the program.
Classroom materials that has not been shipped to participants will be refunded and subject to a $15 cancellation fee to cover credit card fees.
Classroom materials that have been shipped will be subject to $70 cancellation fee to cover materials and shipping fees (materials will not be shipped back to us.)
After the first day of a program, there will be no refunds or credits.
Little Medical School - Region of Waterloo reserves the right to cancel the session due to the number of registrants or any other reason at their discretion and, upon doing so, will refund the registration fee.
Missed classes will not result in make-up classes, prorate tuition or refunds.

Email Subscribtion*

I would like to receive updates about upcoming program registrations.

Email*

Enter Email Confirm Email

Please note: Payment instructions will be sent directly to the email submitted in this form. Preferred payment method is via E-Transfer. Payments made by credit card is subject to a 3% handling charge.

Product Name

Payment Method*

E-Transfer
Credit Card (+3% handling charge)
Bank Payment

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