Age Group (Please check one.)

___ 3 - 4 ___ 5 - 10

Previous Flanders Summer Series attendee? ___ YES ___ NO

Child's Name:___________________________________________________

Date of Birth:___/___/___ M____ F:____ Grade Child Will Enter in September 2008 __________

Parent/Guardian Information
Name: _________________________________________________________

Home Phone _____________________________________________________

Home Address:___________________________________________________

City, State, Zip:___________________________________________________

Cell Phone ______________________________________________________

Name of Workplace _______________________________________________

Workplace Phone Number __________________________________________

Parent/Guardian E-mail: ____________________________________________

Name: __________________________________________________________
Home Phone _____________________________________________________

Home Address:____________________________________________________

City, State, Zip:____________________________________________________

Cell Phone _______________________________________________________

Work Name & # ___________________________________________________

Parent/Guardian Email: _____________________________________________

Allergies?
___ NO

___ YES, please explain __________________________________________________________

Special Needs?
___ NO

___ YES, please explain ___________________________________________________________

Emergency Medications __________________________________________________________

Other Medical Issues _____________________________________________________________

Child's Doctor ___________________________________________________________________

Doctor's Phone ___________________________________________________________________

Child's Dentist ___________________________________________________________________

Dentist's Phone ___________________________________________________________________

Please indicate any other information which would be helpful in planning for your child.
_________________________________________________________________________________

Emergency Information
Contacts (who have my permission to make decisions for the health and welfare of my child,and who can remove my child from the premises of Flanders Nature Center & Land Trust).

1) Name__________________________________
Relationship_______________________________
Address _____________________________
____________________________________
Daytime Phone ________________________

2) Name:__________________________________
Relationship_______________________________
Address _____________________________
____________________________________
Daytime Phone ________________________

Releases
If parent(s) or legal guardian(s) cannot be reached in the event of an emergency, I do hereby appoint the staff of Flanders Nature Center & Land Trust to act in my (our) behalf to administer first-aid treatment and/or to authorize unexpected medical, dental, or surgical care and hospitalization for my child. I give permission for my child to participate in all nature trail walks and related outdoor activities, as well as other Flanders Summer Series activities.

I give Flanders staff permission to release my child to the contact individual(s) listed above. These people have my permission to make decisions as to the welfare and health of my child.

I give my permission to Flanders Nature Center & Land Trust to take, use, publish, and reproduce photographs, slides or video of my child for publicity purposes. ___ YES ___ NO


Signature of Parent or Guardian:____________________________________ Date: ____________________

Prined Name of Parent or Guardian____________________________________________________________