Heartland Farm Sanctuary Online Registration

Registration

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Welcome to Heartland Farm Sanctuary! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Account Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Does your child have any accessibility needs that we should be aware of?

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Photo Release (Y/N)?*

Preferred Pronoun

Please click on the Search button below, then choose the program(s) you would like to register for.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Does your child have any accessibility needs that we should be aware of?

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Photo Release (Y/N)?*

Preferred Pronoun

Please click on the Search button below, then choose the program(s) you would like to register for.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Does your child have any accessibility needs that we should be aware of?

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Photo Release (Y/N)?*

Preferred Pronoun

Please click on the Search button below, then choose the program(s) you would like to register for.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Does your child have any accessibility needs that we should be aware of?

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Photo Release (Y/N)?*

Preferred Pronoun

Please click on the Search button below, then choose the program(s) you would like to register for.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Does your child have any accessibility needs that we should be aware of?

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Photo Release (Y/N)?*

Preferred Pronoun

Please click on the Search button below, then choose the program(s) you would like to register for.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

I release Heartland Farm Sanctuary and its directors, officers and agents from all liability for injury, illness, death, property damage, and related medical care or other costs resulting from my child's visits. Signing this document indicates you acknowledge and accept this waiver/release.