Seasonal Program Registration Form
Mail or fax form to : Ashland Nature Center , P . O . Box 700 , Hockessin , DE 19707 Fax : 302.239.2473 Candy @ DelNature . org Or : Abbott ’ s Mill Nature Center , 15411 Abbotts Pond Road , Milford , DE 19963 Fax : 302.422.1849 Matt @ DelNature . org
You may also register online at :
DelNature . org / Programs Person Filling Out Form : _______________________________________________________ Home Phone : (______)______________________ E-Mail :______________________________________ OK to receive Email from us : ¨ How did you find us ? _________________________________________________________ Address :___________________________________________________ City :_______________________________________ State :________ Zip :____________ Registrant ’ s Name :_____________________________________________________________ Child ’ s Birth Date :_________________________ ¨ Male ¨ Female Program Title : ________________________________________________________ Code :______________________ Date :_________________ Fee : $_____________ Program Title : ________________________________________________________ Code :______________________ Date :_________________ Fee : $_____________ Program Title : ________________________________________________________ Code :______________________ Date :_________________ Fee : $_____________ Registrant ’ s Name :___________________________________________________________ Child ’ s Birth Date :_________________________ ¨ Male ¨ Female Program Title : ________________________________________________________ Code :______________________ Date :_________________ Fee : $_____________ Program Title : ________________________________________________________ Code :______________________ Date :_________________ Fee : $_____________ Program Title : ________________________________________________________ Code :______________________ Date :_________________ Fee : $_____________
For additional registrants , attach additional pages to this form .
Confidential Medical & Required Emergency Information ( For children under 18 without parent supervision ): Please list any medications , allergies ( including food allergies ), physical disabilities , or restrictions that the instructors should know about : ____________________________________________________________
Not a Member ? Sign up below and save : � �
Individual $ 40 ¨ Super Saver Individual $ 30 ( Over 60 or F / T Student ) Household $ 55 ¨ Household Plus $ 85 ¨ Grandparent $ 55
____________________________________________________________ � Protector $ 150 ¨ Patron $ 500 ¨ Guardian $ 1000 +
My child ’ s physician ’ s name & phone #:____________________________________ ____________________________________________________________ My child ’ s medical insurance is : _____________________________________
Full Names of all Household Members : Adult :_______________________ Email :____________________________
Policy #: ____________________________________________________________ Work Phone : ____________________ Cell Phone : ____________________
¨ Yes ¨ No : In case of emergency , I give permission to have my child ( ren ),
__________________________________________ receive first aid and be transported to the nearest hospital by professional , emergency personnel . I understand I will be financially responsible for the cost of such treatment .
_____________________________________________________________ ( parent / guardian signature ) date
Adult :_______________________ Email :____________________________
Work Phone : _____________________ Cell Phone : __________________ Child : _________________________ Birth Date :_______________ ¨ M ¨ F
Child : _________________________ Birth Date :_______________ ¨ M ¨ F Child : _________________________ Birth Date :_______________ ¨ M ¨ F
Payment Information ( credit card information will be kept secure ):
Child : _________________________ Birth Date :_______________ ¨ M ¨ F
Enclosed for programs : $___________, for memberships $__________ Total enclosed : $__________ ¨ Check Credit Card : ¨ Visa ¨ MC ¨ Disc ¨ Amex ( payable to Delaware Nature Society )
Credit Card #: __________________________________________ Exp . Date _____/______( mm / yy ) 3-digit Security Code ( from back of the card ) ____________
Authorized Signature :________________________________________________________________________________
Policies
Payments & Discounts All programs must be paid in full at the time of registration either by check or credit card . We can ’ t hold spaces pending receipt of payment . To receive member discount rate , your membership must be current through the date of your scheduled program . We reserve the right to charge the Non-member rate for programs that occur after the expiration date of your membership .
Refunds and Cancellations Requests for withdrawal 5 business days or more prior to the scheduled program date will be honored . Requests less the 5 business days will be issued if the slot is filled or at the discretion of the Education staff . Programs may be canceled due to low enrollment . Full refunds will be issued for program cancellations .
Inclement Weather Programs will be held rain , snow , or shine . Please dress accordingly . In case of inclement weather , activities may be modified and moved indoors . Programs may be canceled ( and rescheduled or refunded ) due to severe weather at the discretion of our Education staff .
Photographs / Video Delaware Nature Society reserves the right to use any photos / video / artwork of program participants to promote our mission unless otherwise notified in writing .
Delaware Nature Society 31