Registration Form

A Wild Home LLC must receive a registration form & payment to secure enrollment.

If you are paying with StepUp funds, please complete the registration form below & log into your Step Up portal and:

Go to Marketplace
Click on Find Providers
Search for A Wild Home
Select Wild School, as well as the one-time Journal Fee (if new student) or the monthly payment for Village Days

If you are paying out-of-pocket, please complete registration form below & wait for an email response with a reply signifying a spot for your child & secure online payment instructions.

Fill out a form once for each child you are registering.

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Thank you sincerely! Your message has been sent & you will receive a response via the email you provided.

Section 1: Participant Information

Child’s Full Name

Preferred Name (if different)

Date of birth (YYYY-MM-DD)

Age

Allergies or medical concerns

Neurodivergent needs or learning accommodations (if applicable)

Medications (if applicable)

Section 2: Caregiver Information

Primary Caregiver’s Full Name

Relationship to child

Phone number

Email address

Secondary emergency contact (name, relationship)

Secondary emergency contact (phone)

Authorized pick-up persons names (photo ID required for new faces)

Section 3: Waiver & Liability Release

By clicking this box, I acknowledge and agree to the following:(required)

1) I understand that participation in this program involves inherent risks associated with outdoor and “risky play” activities, which may include but are not limited to: bee stings, insect bites, slips/falls, climbing, water play (including the use of a water slide), weather exposure, and minor scrapes or bruises. 2) I recognize that this program is held primarily outdoors, with restroom access available. 3)I voluntarily assume all risks of participation and hereby release, waive, discharge, and hold harmless Amanda Jo Boener, John August Boener, A Wild Home LLC, the homeowners at 241 Pryor Street, Brooksville, FL 34601, and any staff or volunteers from any and all liability, claims, or demands arising out of participation. 4) I understand that this is an educational program and not a licensed daycare facility.

Section 4: Consent & Expectations

By click this box you agree to;(required)

1) the community values to have respect for nature, tools, the land here, our individual selves, & peers- To Cultivate Community, Celebrate Curiosity, & Nurture Wonder, with Nature. 2) the use of tools (for example; whittling knives, gardening tools, mushroom spawn, etc.) 3) give permission for the child to engage in wildschooling activities such as foraging, journaling, mindfulness, animal interaction, & seasonal acknowledgments (not tied to spiritualism or religion).

Section 5: Media Release

Please indicate your level of comfort with how A Wild Home may use images or videos of your child for educational or promotional purposes (website, media, social media, or printed materials):(required)

Full Permission – I give permission for photos/videos of my child to be used. (preferred) Limited Permission – I give permission for photos/videos of my child to be used only if their face is not visible (e.g., back of head, hands, nature work, group activity from a distance, or if their face is blurred or obscured during editing).

Section 6: Private Program Media Sharing

A Wild Home is rooted in community, connection, and shared experience. Photos and videos are shared privately with people who have enrolled in A Wild Home programs via email or private community platforms (such as newsletters and parent updates). This allows participants and caregivers to stay connected to what is being explored and created within the community. By enrolling, you agree to this private sharing. Content will not be posted publicly without separate permission.

Section 7: Payment & Cancellation Policy

Click link HERE to view the Registration, Payment, & Cancellation Policy.

How will you be paying?