Enrollment

🍁 Fall Semester & Summer Overnights
🌞 Summer Day Sessions
⚕️Medical Form
🌙 Rising Moon

Access the new registration system below for Fall Enrollment and Overnight Summer Programming.

We appreciate your patience as we navigate this transition!

Enrollment Form

One per family

Summer Day Sessions Registration

Overnight Summer Session enrollment is in our new registration system.
Click on "Fall Semester & Summer Overnights" at the top of this page.

Your Information

First Name *

Last Name *

Phone *

Home / Work / Cell / Other *

Email *

Alternate Phone

Address *

Town *

Zip Code *

State *

Same as Student Address? *

Yes No

Relationship to Student *

Participant Information

First Name *

Last Name *

Age on January 1, 2022 *

Cell Phone

Day Sessions: *

Hampden: June 27 - July 1

Deer Isle: July 4 - July 8

Monroe: July 25 - July 29

Monroe: August 8 - August 12 (waitlist for ages 2-7)

Previous Education *

Public School

Private School

Homeschool

Unschooling

Other

Overnight Summer Session and Fall enrollment is in our new registration system.
Click on the left most tab at the top of this page.

Second Participant? *

No Yes

Second Contact

First Name *

Last Name *

Email *

Relationship to Student *

Phone *

Home / Work / Cell / Other *

Alternate Phone

Address *

Town *

Zip Code *

State *

Enrollment Form

One per family

Medical Information

Participant Information

Please fill out a separate form for each participant.

First Name *

Last Name *

Date of Birth *

Pre-existing medical conditions or diagnosis? *

No Yes

If yes, please describe:

Medications? *

No Yes

List medications and dosages:

Emergency Contact *

Relationship to Participant *

Allergies? *

No Yes

List allergies and reactions:

Hospitalization within the past year? *

No Yes

If yes, please describe:

Emergency Contact Phone *

Emergency Contact Secondary Phone

Primary Care Physician *

Physician Phone *

Significant event(s) affecting the participant's life? *

No Yes

(Family changes, death of a loved one, adoption, survived a disaster, etc)

If yes, please describe:

Worked with professional to address mental or emotional health concerns in the past year? *

No Yes

If yes, please describe:

Is there anything about the program that your child is wondering about or worried about?

What have we forgotten to ask?

Additional information that you think important or that may affect their ability to fully engage with the program.

Your Information

First Name *

Last Name *

Do you give permission for your child to carve with a knife? *

Yes No

Mentors will demonstrate and reinforce knife safety. Participants are required to wear a glove on their non-carving hand and will be supervised while carving.

This health history is correct and accurately reflects the health status of the participant to whom it pertains. I understand the information on this form will be shared on a “need to know” basis with program staff. I give permission for this form to be printed. *

Yes No

I acknowledge that participation in White Ash Learning programming has an inherent risk. The child named above has my permission to participate in White Ash Learning programming. I understand that participation may involve activities which could result in injury. I certify that my child is in healthy physical condition and is fully able to participate. *

Yes No

I assume all risk incidents to my child’s participation and release White Ash Learning, its employees, agents, and volunteers from all liability, claim, expenses and actions which may arise from injury or harm to the child as a result of participation. In the event of a medical emergency, I authorize White Ash Learning to designate a hospital, physician or emergency personnel to provide care (including hospitalization, if necessary) to the child and release White Ash Learning from any liability for injury or harm which to the child which may result from this medical care. I understand that responsibility for payment of such care medical care will be mine and certify that the child is covered by adequate medical insurance. *

Yes No

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. White Ash Learning has put preventative measures in place to curtail the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected. Further, attending White Ash Learning programming could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending White Ash Learning programming, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at White Ash Learning programming may result from the actions, omissions, or negligence of myself and others, including, but not limited to, White Ash Learning staff, volunteers, program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at White Ash Learning programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless White Ash Learning, its staff, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of White Ash Learning, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any White Ash Learning program. *

Yes No

I have carefully read this agreement and fully understand the contents. I am aware that this is a release of liability and a contract among myself, White Ash Learning, and/or their affiliated organizations, and sign it of my own free will. *

Yes No

I give consent to photographing or recording me or my child in connection with White Ash Learning programming. I grant to you, your successor, assigns and licensees the perpetual right to use all the motion pictures, photographs, and audio recordings which you may make of me or my child, and the right to use said media in or in connection with marketing or publicly displaying the programming. *

Yes No

Parent or Guardian Signature *

Your Email *

Date *

Enrollment Form

One per family

Medical Form

One per participant

Payment

Full tuition or deposit

Url

Rising Moon Registration

Your Information

This form is intended for each participant to fill out.

First Name *

Last Name *

Email *

Phone *

Home / Work / Cell / Other *

Address *

Zip Code *

Town *

State *

Age on June 1, 2022? *

Date of Birth *

I am registering for: *

Summer Session I (July 18 – 22)

Summer Session II (August 1 – 5)

First Moon Adult Rite of Passage

Emergency Contact Information

First Name *

Last Name *

Phone *

Home / Cell / Other *

Email *

Alternate Phone

Relationship *

Second Contact

First Name

Last Name

Phone

Home / Cell / Other

Alternate Phone

Relationship

Do you have any dietary restrictions or preferences?

Questions for us?

Enrollment

Access the new registration system below for Fall Enrollment and Overnight Summer Programming.

We appreciate your patience as we navigate this transition!

Enrollment Form

Medical Form

Payment

Summer Day Sessions Registration

Overnight Summer Session enrollment is in our new registration system. Click on "Fall Semester & Summer Overnights" at the top of this page.

Your Information

Participant Information

Second Contact

Enrollment Form

Medical Form

Payment

Medical Information

Participant Information

Your Information

Enrollment Form

Medical Form

Payment

Rising Moon Registration

Your Information

Emergency Contact Information

Second Contact

Overnight Summer Session enrollment is in our new registration system.
Click on "Fall Semester & Summer Overnights" at the top of this page.