Chintimini Wildlife Center 2010 Summer
Program Registration
Form
Child's Name:__________________________________________Age:____
Parent/Guardian Name:
___________________________________________________________________________
Address: ___________________________________________City____________________State:_____Zip:________
Work Phone:
_______________________ Home Phone:
_________________________Cell:____________________
Email:_______________________________Emergency
Contact & Phone:___________________________________
For Camp participants
please circle: T-shirt size: Adult
or Youth S
M L
Youth Camps – M-F 9am-4pm
CSI Wildlife Detectives (ages 9-12) June 28-July 2 - $165 ________
Wildlife Rehabilitator’s Camp (ages 12-15) July 12-16 - $165 ________
Raptor Rangers Camp (ages 7-9) July 26 - 30 - $165 ________
Family Wildlife Days – Saturdays - $20/family or $5/each (age 3 & under free)
June 26 - Pond Exploration ________
August 7 – Mammals on the Move ________
Evening Programs – Wednesdays 7-8 PM - $5 per person
Evening Nature Walk – July 7 ________
Meet the Raptors & Their Handlers – July 21 ________
Meet the Raptors & Their Handlers – August 18 ________
Total
Fees: $___________
Allergies/Medical Info (campers):____________________________________________________________________
I hereby certify that I am the
legal parent or guardian of the child. I understand and assume the risks of
participation in this program. For myself, my heirs and assigns
I agree to waive, release and forever discharge any claim for injury or damage,
and hold harmless Chintimini Wildlife Center, its officers agents, volunteers
and employees against any claim, loss, liability or expense including
attorney's fees, resulting directly/indirectly from participation.
I give CWC permission to
include my child in photographs that may be used in brochures, newsletters and
other media. __________(initial)
Signature:
________________________________________________________ Date: ________________
Print Name:
_______________________________________________________
Please mail to: CWC, 311 NW Lewisburg Ave., Corvallis,
OR 97330