Butterflies of Wellness 2026 Enrollment Form

Enrollment & Required Form

You’re almost in!

To reserve your child’s spot in Butterflies of Wellness, please complete the required enrolment forms below. These include program disclosures, waivers, and permissions needed to keep your child safe and supported. Once your forms and payment have been submitted, your child will be officially enrolled.

Please note that a minimum of 3 weeks participation is encouraged but full participation in all 6 weeks yields the best results.

Estimated time: 5–8 minutes

Tip: Use your child’s legal name as it appears on school/medical records

What You’ll Complete Today

By submitting these forms, you will:

Confirm your child’s enrollment details
Review important program disclosures (including that this is not therapy)
Sign our participation waiver and NJ hold harmless agreement
Review our no-refund policy (specialized program planning and staffing)
Provide emergency contact and basic health/safety information

Waves of Wellness Summer Kids Program Payment form

Child & Guardian Details

Child’s Full Name

Child’s Current Age

Relationship to Child

Email Address

Child’s Date of Birth

Parent/Guardian Name

Primary Phone Number

Communication Preference

Home Address

Address Line 1

City

State

Zip Code

Emergency Contacts & Authorized Pickup

Emergency Contact #1

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Emergency Contact #2

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Authorized Pickup List

Authorized Pickup Name

Authorized Pickup Relationship

Authorized Pickup Phone Number

Note: Staff will verify photo IDs for any unfamiliar adult at pickup.

Medical & Nutrition Logic

Medical Conditions/Medications

Allergy Information

I acknowledge that Butterflies of Wellness/SJCC staff will not administer medications or injectables, including Epi-Pens.

Snack Consent

Option A- I give permission for my child to receive program-provided snacks.

Option B- I do not give permission. I will provide “brown-bag” snacks.

Reminder that parent-provided snacks are limited to small items like fruit, yogurt, or juice boxes (max 6oz).

Child Strengths & Support Profile

Calming Techniques: What helps calm your child?

Triggers: Any sensitivities or triggers we should know about?

Interests: List your child’s strengths and motivators.

Program Logic & Weekly Selection

Programs are sold per week

You must select a minimum of three (3) weeks.

Programs

Week 1: July 6 – July 9

Week 2: July 13 – July 16

Week 3: July 20 – July 23

Week 4: July 27 – July 30

Week 5: August 3 – August 6

Week 6: August 10 – August 13

Attendance Policy Acknowledgement: I understand the program starts at 9:00 AM and no child will be accepted more than 15 minutes late.

Dress Code Agreement: I agree to the dress code: shirts must touch the child’s bottom, and bottoms must be no more than 2 inches above the knee.

Program Disclosure: Not Therapy

Butterflies of Wellness is a clinician-led summer enrichment program focused on mental health–inspired skill-building through education, structured activities, movement, and play-based learning.

This program is not psychotherapy, counseling, or clinical treatment, and participation does not create a therapist–client relationship. This program does not diagnose, treat, or provide medical or mental health services.

If your child is experiencing a mental health crisis or needs clinical treatment, please contact a licensed provider or call 911 in an emergency.

Consent to Participate

I give permission for my child to participate in Butterflies of Wellness, including indoor activities and structured outdoor games (no playground equipment). I understand that activities are designed to be age-appropriate and supervised, but participation includes inherent risks as described below.

Assumption of Risk & NJ Hold Harmless Agreement

I understand that participation in a youth enrichment program may involve risks, including but not limited to: slips, falls, minor injuries, allergic reactions, emotional discomfort during learning activities, and other unforeseen risks associated with group participation, movement activities, creative materials, and outdoor games. I voluntarily assume all such risks, known and unknown, to the fullest extent permitted by law.

Release of Liability / Hold Harmless (New Jersey)

To the fullest extent permitted by New Jersey law, I, on behalf of myself and my child, release, waive, discharge, and agree to hold harmless and indemnify Butterflies of Wellness and its owners, directors, officers, employees, contractors, volunteers, affiliates, and agents (collectively, the “Released Parties”) from any and all claims, demands, causes of action, damages, losses, liabilities, costs, or expenses (including reasonable attorneys’ fees) arising out of or related to my child’s participation in the program, including claims resulting from the negligence of the Released Parties, except to the extent caused by gross negligence, recklessness, or intentional misconduct.

Scope

This release applies to any injury, illness, property loss, or other damages that may occur on-site, during program activities, or while participating in any program-related experience.

Severability

If any portion of this agreement is found unenforceable, the remaining portions shall remain in full force and effect.

Medical & Emergency Authorization

In the event of an emergency, I authorize program staff to:

Contact emergency medical services (911), and
contact me and/or my listed emergency contacts as soon as possible.

If I cannot be reached, I authorize the Released Parties to obtain emergency medical evaluation and treatment for my child as deemed necessary by medical professionals.

I understand I am responsible for any medical costs incurred.

Medication Policy

I understand that Butterflies of Wellness does not administer medications, including rescue inhalers, antihistamines, or epinephrine auto-injectors. If my child requires medication administration to participate safely, I agree to discuss this with the program in writing, prior to the start date to determine whether participation is appropriate.

Behavior & Safety Expectations

I understand the program maintains a structured environment for safety and learning. If my child’s behavior presents a safety risk to themselves or others, or significantly disrupts the program, the program may require early pickup and/or dismissal from the program without refund or credit.

Payment, Scheduling, and No-Refund Policy

Because Butterflies of Wellness is a specialized program that requires advance staffing, planning, materials, and limited-capacity scheduling, I understand and agree to the following:

All payments are non-refundable.
There are no refunds or credits for missed days, schedule conflicts, early withdrawal, or dismissal due to behavioral or safety concerns.
The deposit is non-refundable and secures the spot, and is applied toward tuition.
If I am using autopay, I understand that I am responsible for the payment terms selected at enrollment, including any minimum commitment stated in the payment plan.

Photo/Media Release (Optional)

Choose one:

Photo/Media Release

Yes, I grant permission for my child’s photo/video to be used for program-related marketing (website, flyers, social media).

No, I do not grant permission.

After You Click Submit: What Happens Next

Once you submit your forms:

You’ll receive a confirmation email within a few minutes.
Within 1 business day, you’ll receive a Welcome & Logistics Email including:

start date confirmation and schedule (Mon/Wed/Thu, 9:00 AM–12:00 PM)
location details: 1310 Kings Highway N, Cherry Hill, NJ 08034
arrival & pickup procedures
what to bring / what not to bring
snack information and allergy reminders
contact number during program hours: 267-225-1972
payment plan confirmation (if applicable

If you do not receive the confirmation email, please check spam/junk, then text/call 267-225-1972.

Electronic Signature

By typing my name below, I understand that I am signing electronically and that my electronic signature is legally binding. I confirm I have read, understood, and agree to all terms above.

Name

Date

No payment items has been selected yet

Pay with Card (Stripe)

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