1 Shelly's Weekend Workshops Registration From

What dates would you like to register for?*

Week 1- Oct. 29th, 2022Week 2- Nov. 5th, 2022Week 3- Nov. 12th, 2022

Will you be staying with your kid(s)?*

yesno

Parent/Guardian Name (1)*

Parent/Guardian Name (2)

Child's Name (1)*

Age*

Child's Name (2)

Age

Child's Name (3)

Age

Child's Name (4)

Age

Address*

City/State/Zip*

Email*

example@example.com

Mobile Phone*

Alternative phone number

you must have a mobile phone number to drop off your child. In the case of an emergency workers will need a way to get in touch with you. If possible, please provide a second way to reach you. Please list any medical conditions that we should be aware of. If you are registering multiple children, please include the name next to the medical condition. Be advised that staff at HVKBP are not authorized to administer or supply medications to any child:

Please list any medical conditions that we should be aware of. If you are registering multiple children, please include the name next to the medical condition. Be advised that staff at HVKBP are not authorized to administer or supply medications to any child

Emergency Contacts: Please provide a contact that can be reached in case of an emergency, other than you?

Name

Phone number

Relation to child

IF you are dropping off, please provide a list of all people (including yourself) that is authorized to pick up your child from the workshop event:

Anyone picking up a child will need to provide a photo ID

In the case of an emergency or medical situation, HVKBP staff will contact emergency services and medical personnel. Based on their assessment, your child may be transported to a local hospital to receive care. Liability Waver 1, including my partner, child/ children/ other family members and heirs-release and hold harmless the Historic Virginia Key Beach Park m, its employees, volunteers, board members, officers, and related parties from all liability for lost or stolen personal items, injuries, or losses as a result of attending and/or participating in any class, program, tour, or other function of the Park whether on-site, off-site or in transit.

I authorize the Historic Virginia Key Beach Park to take photographs of my child/ children for marketing purposes and give permission for these images to be used in printed and online materials, including advertisements, brochures, flyers and websites.

Signature*

Date*

Date

Shelly's Weekend Workshops Registration From

VIRGINIA KEY BEACH PARK TRUST CREDIT CARD AUTHORIZATION FORM