REGISTRATION 2017

To be completed by Parent or Guardian

  • Please print in ink.
  • All sections must be completed for registration.
  • Complete one registration form for each child you are enrolling.
  • Copy form as needed
  • Payment in full must accompany this form.

STUDENT INFORMATION

Last Name First Name Gender: Male Female

Date of Birth Age School Attending Last Grade Completed

PARENT/GUARDIAN INFORMATION

Relationship to minor: Last Name First Name

E-mail Address

Street Address City State Zip

Home Phone Work Phone Cell Phone

MEDICAL TREATMENT AUTHORIZATION

Complete insurance information is required – all children must have medical insurance to attend summer field studies program.

In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency, I give my consent to contact Emergency Medical Service provider, and agree to release any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. I understand I am responsible to submit any claims to my health insurance company for reimbursement for any medical services provided.

I understand that, in accordance with Environment Erie program policy, the medication(s) should be given at home before and/or after the program. However, when this is not possible and medications will be brought to the youth program, I agree to read and comply with the provisions outlined in the program welcome letter relating to the management of medications. You will receive your welcome letter via e-mail upon registration completion.

HIPPA

Environment Erie honors the privacy of the participants in its programs and complies with the national regulations regarding health information.

Will the youth need to take any medication during the program? NO YES (Please circle one)

If YES, please list the specific prescriptions or over-the-counter medications below, reasons for medications, and daily dosage. If any medications change prior to arriving at the program, please provide an updated list upon arrival. (All medication must be administered and held with staff.)

Medication Reason(s) for medication Daily Dosage/Time(s) taken

Name of emergency contact Phone

Name of child’s Physician Is physician authorization needed?YESNO Phone

Insurance company policy subscribers name Place of employment Policy No. Group No.

HEALTH HISTORY (please circle and provide approximate date that youth suffered from allergies and other conditions listed below)

Allergies: Hay Fever Bee/wasp stings Insect stings Penicillin Peanut Other (please list)

Date:

Other: Asthma Diabetes Convulsions Concussion Behavioral/Emotional Other

Date of the most recent tetanus immunization: Has the youth ever been hospitalized? YES NO

Please list any major past illnesses (Contagious and Non-contagious)

Does youth have any chronic or recurring illness?

Is there anything else in youth health history that the program staff should know?

Are there any activities from which the youth should be restricted?

Are there any specific activities that should be encouraged?

Does the youth have any medical appliances (glasses, contact lenses, orthodonture, etc.? If yes, explain:

SIGNATURE (By signing this form, I affirm that the information shared on this form is true and correct)

PROGRAM EXPECTATIONS

Children are expected to respect and be courteous to one another and Environment Erie staff. Disruptive behavior such as hitting, biting, name-calling, and destruction of property will not be tolerated, nor will behavioral problems. Disruptive behaviors will be handled as follows: Warning and discussion with student; parent discussion; if issue is not resolved, student will be withdrawn from the program.

Students will not be permitted to have cell phones or any type of weapon with them at this program. Please urge your child to leave electronic games and music players at home. We will not be responsible for loss of these items.

I have reviewed the program expectations with my child, who agrees to follow these expectations.

RELEASES

I/we, undersigned, individually and as parent(s) and/or guardian(s) of ______, a minor, ask that he she be admitted to participate in the Environment Erie Summer Field Studies Program. In considerations of such admissions, I/we do hereby agree to release, discourage, and hold harmless Environment Erie, its officers, and employees of and from all causes, liabilities, damages, claims or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor’s attendance at the Environment Erie Summer Field Studies Program, or in the course of activities held in connection with the Summer Field Studies Program.

Additionally, I/we authorize Environment Erie Personnel to photograph, videotape, and/or audiotape my/our child in promotion of the Environment Erie Summer Field Studies Program.

SIGNATURE

DID YOU REMEMBER?

1. Complete all sections of this form.

2. Include parent/guardian signatures.

3. Enclose check or cash with full payment along with completed registration form.

4. Complete medical insurance information. All students must have medical insurance coverage to attend camp.

5. Return form and Payment by: June 24, 2016 to:

Environment Erie

301 Peninsula Drive, Suite 5

Erie, PA 16505

PLEASE MAKE CHECKS OUT TO: ENVIRONMENT ERIE

REGISTRATION IS FIRST COME FIRST SERVE. PROGRAM MAY BE FULL UPON RECEIVING REGISTRATION. IF REGISTRATION IS FULL YOU WILL BE NOTIFIED AND REIMBURSED THE FULL AMOUNT.