Withness 2024
September 6 - September 9, 2024
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TRANSLATE THIS FORM: Español, Português, Tiếng Việt, Tagalog, Kreyòl ayisyen
FOR WHOM?
I WILL PARTICIPATE
YOUR (PARENT/GUARDIAN) NAME:
YOUR (PARENT/GUARDIAN) CONTACT INFORMATION:
NAME:
(not parent)
CONTACT INFORMATION:
(OPTIONAL)
BIRTHDATE:
Please enter a valid birthdate here...
GENDER:
Please enter a gender information here...
use button or write in anything!
Male
Female
Non-Binary
PRONOUNS:
use button or write in anything!
He/Him/His
She/Her/Hers
They/Them/Theirs
LANGUAGE:
(only if not English)
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HOUSEHOLD/FAMILY DETAILS:
PARTICIPANT MAILING ADDRESS:
* ONLY IF OUTSIDE OF USA
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PERSONAL INTRODUCTION
TELL US ABOUT YOURSELF:
TELL US ABOUT YOUR CHILD:
What specifically interests you in this program?
What other interests / hobbies / activities do you enjoy?
What specifically interests your child in this program?
What other interests / hobbies / activities do they currently enjoy?
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HOW DID YOU FIND US?
Please help us understand
which of our marketing efforts are most effective
by checking the factor or factors
that most influenced your decision to register!
WORD-OF-MOUTH:
A friend or family member told me about it
WEB:
I searched for something on the internet and found your website
SOCIAL-MEDIA:
I saw something on social media: Instagram, Facebook, etc.
EMAIL:
I received a marketing email or e-newsletter from you
BROCHURE:
I received or read a printed brochure or program catalog
POSTER:
I saw a poster on a bulletin board
PRINT:
I saw a printed advertisement or article in a newspaper or magazine
ADVISOR:
A school counselor, advisor, or paid consultant recommended it to me
ENCOUNTER:
I randomly encountered your staff or students while we were out in the world
EVENT:
I found your table or display at a school, fair, or other public event
MYSTERY:
A mysterious force has led me here; I cannot explain it
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IMPORTANT DETAILS:
DIET:
NONE
Please describe any special dietary restrictions, and indicate whether they result from personal preference, religious custom, or medical necessity.
ALLERGIES:
NONE
Any ALLERGIES?
To foods? To medications? To insect stings or other environmental agents?
If so, please explain the symptoms and the severity of these allergies: ( MILD DISCOMFORT or SEVERE LIFE THREATENING ANAPHYLAXIS )
MEDICATIONS:
NONE
Any regular MEDICATIONS? If so, please list the medications, their dosage and frequency, and their purpose. This information may be used to administer medications during a program, but more importantly it will help medical professionals in the event of an emergency.
CONCERNS:
NONE
Tell us any concerns you may have about participation in our programs: Any
injuries or physical limitations
, or any
emotional, behavioral, or mental health issues
, any
sleep issues
,
substance abuse
, history of
infections
, or anything else that you can let us know in advance to help our staff to make the program safe and enjoyable for everyone.
Please note: failure to disclose significant medical or learning issues undermines our work and the safety of our programs, and we reserve the right to dismiss any participant who arrives with undisclosed conditions.
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YOU MUST CHOOSE ONE OF THESE OPTIONS:
$1,500.00
TUITION A-SUPPORTING-TIER-WITHNESS
This tuition tier supports those paying on the lower end of the scale and helps Journeys develop future programs
$1,220.00
TUITION B-STAFFING-TIER-WITHNESS
This tuition tier covers our full costs with administrative overhead
$935.00
TUITION C-SUSTAINING-TIER-WITHNESS
This tuition tier covers our direct costs of running the program
$650.00
TUITION D-SUPPORTED-TIER-WITHNESS
This tuition tier falls short of covering our direct expenses
$40.00
TUITION Z-FINANCIAL-AID-COMMUNITY-PROGRAMS
We require that everyone applying for financial aid for Community Programs pays at least $40 to secure a spot in the program. After you register, you will receive a Financial Circumstances Questionnaire and your final financial aid determination will be determined based on annual income, family size and answers on your Financial Circumstances Questionnaire
SHOPPING CART
ADJUST QUANTITIES:
ITEM
QUANTITY
SUBTOTAL
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NEWSLETTER OPT IN
Please opt in below to be added to our newsletter email list!
Would you like to be added to our newsletter to receive occasional emails about our programs and community updates?
YES
NO
SUBMIT THIS SECTION
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ALMOST DONE, KEEP GOING!
PLEASE COMPLETE THIS VALIDATION:
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