Totem Outdoor School Application Child's First & Last Name* First Last NicknameDate Of Birth Date Format: MM slash DD slash YYYY Grade*Parent 1 Name* First Last Parent 1 Cell*Parent 1 Email Address* Parent 2 Name First Last Parent 2 CellParent 2 Email Address* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Name* First Last Emergency Phone Number*Food IntoleranceAllergiesEpi Pen Provided*YesNoMedical ConditionsAny Behavioral ConcernsName Of Insurance*Policy Id Number*Driver Pickup ConsentTotem Outdoor SchoolFall 2021 Session - $1,000All sessions are 9:30AM - 3:00PM No class on Nov 26thWednesdays: Sept. 8th - Dec. 15th 2021Fridays: Sept. 10th - Dec. 17th 2021noneWinter 2022 Session - $500All sessions are 9:30AM - 3:00PMWednesdays: Jan. 5th - Feb. 23rd 2022Fridays: Jan. 7th - Feb. 25th 2022noneSpring 2022 Session - $1,000All sessions are 9:30AM - 3:00PMWednesdays: Mar. 2nd - Jun. 22nd 2022Fridays: Mar. 4th - Jun. 24th 2022noneTotem Outdoor CampsTotem Outdoor Camps Price: $220.00 Quantity: Choose Camp Sessions - $220/Camp SessionAll sessions are 9:30AM - 3:00PM Session 1: June 29th, 30th & July 1st Session 2: July 13th, 14th & 15th Session 3: July 27th, 28th & 29th Pay all now or monthly?*If you decide to pay monthly, you will pay $275 per child per month. If you pay total now, you will be taken to Paypal to make your payment. You do NOT need a Paypal account to pay. Select "Pay with Debit or Credit Card" in next Paypal screen if needed.Pay all now onlinePay monthly onlinePay via checkOnline Processing FeeWe provide online payment to our families as a convenience. If you prefer not to pay the online processing fee please bring your check to the shool. Price: $0.00 Total $0.00 Financial Obligations* I understand the financial obligations to Totem Outdoor School (Totem Preschool LLC). There are no refunds, credits or transfers of payments. Liability Release Statement* This applicant has my permission to participate in activities and events organized by Totem Outdoor School (Totem Preschool LLC). I hereby release from liability and financial obligations directly or indirectly to include teachers, staff and instructors of Totem Outdoor School (Totem Preschool LLC). I understand in a case of an accident or illness, Totem Outdoor School (Totem Preschool LLC) has my permission to secure emergency medical attention.