Registration - Trillium Lutheran Church

Our capacity is limited, so please only complete this form if you have received a welcome email from nathan@trilliumwaterloo.ca.

Trillium Lutheran Church is excited to be collaborating with our neighbourhood to make the “Village Pop-Up School” a reality during this difficult time, under the leadership of Lisa Kiernander.

Village Pop-Up School

Use this form to register a child in the Trillium Village School program. You will need to enter your child's health card number. If you have questions about registration contact nathan@trilliumwaterloo.ca. This program is dependent on parent volunteers so that we can maintain a safe child/adult ratio, as well as a low cost to families. We ask that one parent (or grandparent) from each family volunteer to help supervise the program once a week. The volunteer will need a vulnerable sector check. See the welcome email for more information.

Parent/Caregiver Information

Enter information about yourself and any other parents or caregivers who have permission to pick up your child.

Name (Parent/Caregiver)(Required)

Enter your name here.

First Last

Email(Required)

Enter your email address.

Enter Email Confirm Email

Phone(Required)

Enter your phone number.

Address(Required)

Enter your address.

Street Address Address Line 2 City Province Postal Code

Emergency Contact (1)(Required)

Enter the name of another parent, caregiver or emergency contact. In case of an emergency, we will contact this person if we cannot reach you. This person with have permission to pick up your child. You have the option to add additional caregiver permissions below.

Name Phone

Emergency Contact (2)

Name Phone

Additional caregiver with pick up permission. (1)

Add the name and phone number of an additional adult who has permission to pick up your child from the program. (optional)

Name Phone

Additional caregiver with pick up permission. (2)

Add the name and phone number of an additional adult who has permission to pick up your child from the program. (optional)

Name Phone

Participant Information

Enter information about the child you are registering in the program.

Name of Participant(Required)

Enter the name of the child you are registering in the program. If you are registering more than one child, please complete an additional registration form for each child.

First Last

Participant Pronouns(Required)

example: she/her, he/him, they/them etc.

Participant Date of Birth(Required)

MM slash DD slash YYYY

Participant Grade(Required)

Choose the grade of your child for the current school year (2024-2025). This program is recommended for children in SK through Grade 6. Contact nathan@trilliumwaterloo.ca if you have any questions.

Peers or Friends

Add the names of any participants who you would like to have grouped with your child. Small groups will be divided by age, but we will do our best to respect your request.

Health Card Number

Enter the health card number of the child you are registering, if they have one.

Dietary Needs and Food Allergies

Please enter your child's dietary needs and/or food allergies. If you child has an anaphylactic allergy, please indicate this and make sure they bring their epi-pen with them to the program.

Other Allergies, Health Conditions and Medication

Please use this field to tell us about any other medical needs your child may have. If your child normally takes medication during the program hours, please indicate the medication and dosage. If you child has an anaphylactic allergy, please indicate this and make sure they bring their epi-pen with them to the program.

Exceptionalities, Learning Accommodations, Accessibility & Inclusion Needs

Please use this field to tell us about any exceptionalities, accessibility or inclusion needs your child may have. If your child has an IEP or would benefit from learning accommodations, please include a detailed description here.

Risky Play(Required)

Participants will have opportunities to use age appropriate sport and playground equipment in a supervised environment. Staff & volunteers will monitor risks and to work with participants to set and enforce boundaries that will ensure everyone's safety. However, due to the nature of the equipment and activities, it is possible that participants may fall or be injured. We actively work to assess and mitigate risks, however we believe that some degree acceptable risk is an appropriate and inherent part of play, supports a child's personal and physical development, and helps to develop resilience. Unacceptable risks include concussions, broken bones, and eye injuries. Acceptable risks include nosebleeds, bruises, skinned knees, and twisted ankles. If you have questions about our approach to risky play, please contact Nathan at nathan@trilliumwaterloo.ca.

I have read and understand the Risky Play Policy.

Walking Field Trips: Mary Allan Park(Required)

The program may take walking field trips to Mary Allan Park.

I understand that program leaders may take my child off site to access Mary Allan Park.

Use of Technology(Required)

Participants are permitted to use devices and technology to engage in synchronous and asynchronous learning activities and are asked not to use devices for other purposes (streaming shows, music, online games etc.)

I will discuss appropriate use of devices with my child.

Code of Conduct

You and your child(ren) agree to adhere to the code of conduct of Elizabeth Ziegler PS.

I agree.

Photo and Media Permission(Required)

We would like to be able to take photos of students participating in the program. We may use photo or video recordings of your child on our website, on facebook and instagram accounts or in print. If used, child's name will not appear with the content. If you select "No, thanks" your child's photo may appear but their face will not be visible. For example, the back of their head might appear in an action shot of children participating in an activity.

Yes, I consent to photo and media permission as described.

No, thanks.

Program Dates

Registration

My child will participate in the program on(Required)

Select all that apply:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Wednesday Extended Day(Required)

Footpaths after-school camp takes place on Wednesdays at Trillium from 3:20-5:45, followed by a family meal. If your children are not already participating in Footpaths, they are invited to stay and join in the program at no additional cost, and we would be delighted if your family joined us for the free meal.

Footpaths: Child is already participating.

Footpaths: Yes, please include my child.

No thanks: Regular Wednesday pick up time.

Total

Amount Due per Program Week

Please arrange payment in a lump sum or on a weekly basis. We accept payment via E-transfer, cash or cheque. If you wish to pay via etransfer, please send the registration fee to office@trilliumwaterloo.ca and include your child's name in the memo line along with the phrase "Village week 1" or "Village week 2" etc. Cheques should be made out to "Trillium Lutheran Church". Cash or cheque payments can be brought to the Trillium Church office at 22 Willow during regular business hours or dropped in the mail slot.

Payment Options(Required)

Please include the child's name and session/date with your payment. This may be on an envelope, on the memo line of a cheque, or as the message in an e-transfer (i.e. "Amy Jones Village weeks 1 and 2")

E-Transfer: I will send an e-transfer to office@trilliumwaterloo.ca

Cash or Cheque: I will deliver or mail payment to 22 Willow Steet, Waterloo ON

Cash or Cheque: I will bring payment on my child's first day of the program.

Please Waive my Fee (Financial Need)

Phone

This field is for validation purposes and should be left unchanged.