Wildlife Adventure Club Registration Form
Please complete the form below to register your child for our summer programs.
Club Camper Information
Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
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September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2019
2018
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2016
2015
2014
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2012
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Year
Age
*
Any allergies?
*
No known allergies
List allergies here
Any activity the child should be restricted from?
*
Any physical, cognitive or other condition that would require special attention or medication while at Wildlife Adventure Club?
*
Parent/Legal Guardian Information
Parent/Legal Guardian
*
First Name
Last Name
Relation
*
Email Address
*
example@example.com
Cell/Home Phone
*
Work Phone
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Parent/Legal Guardian (optional)
Parent /Legal Guardian 2
Relation 2
Email Address 2
example@example.com
Cell/Home Phone 2
Work Phone 2
Additional Emergency Contact
Emergency Contact Name (if parent or guardian is not available)
*
Emergency Contact Relation
*
Emergency Number
*
Emergency Number #2
Pick-up/Drop-off Authorization
Please list the names of ALL individuals who are authorized to pick-up your camper (must include parents/guardians and emergency contacts entered above).
*
Photo/Media Release
I agree that photos of my child can be taken and used in marketing materials.
*
Yes
No
Animal Interaction Agreement
Please note that Wildlife Adventure Club campers will not be allowed to handle live birds of prey or interact with any of our wildlife rehab patients. Some interaction with reptiles and invertebrates within the Wildlife Education Animal Ambassadors may be allowed. Chintimini Wildlife Center Staff reserves the right to revoke interaction privileges if your child does not follow animal safety rules.
*
I agree
Food/Snacks
Each child must bring a lunch with them. Please note that if a child attending has a food allergy, parents may not be able to include certain items in lunches. CWC Staff will notify parents of any restrictions prior to the club day.
*
I Agree
Camp Selection & Payment
Register & Pay:
Categories:
All
All
7-11 years
12-14 years
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( X )
7-11 years
June 19th: Wild About Wetlands!
9am-1pm. For ages 7-11.
$
100.00
June 29th: Take Flight
9am-1pm. For ages 7-11. **Club campers will not be allowed to handle live birds for the safety of the child and the animals.
$
100.00
July 3rd: Wilderness 101
9am-1pm: For ages 7 - 11.
$
100.00
July 12th : Junior Wildlife Rehabbers
9am-1pm. For ages 7 - 11. **Club campers will not be allowed to interact with live rehab animals for the safety of the child and the animals.
$
100.00
12-14 years
June 21st: Wild About Wetlands! 2
9am-1pm. For ages 12-14.
$
100.00
June 26th: Take Flight
9am- 1pm. For ages 12-14. **Club campers will not be allowed to handle live birds for the safety of the child and the animals.
$
100.00
July 6th: Wilderness 101
9am-1pm. For ages 12 - 14.
$
100.00
July 10th: Junior Wildlife Rehabbers
9am-1pm. For ages 12 - 14. **Club campers will not be allowed to interact with live rehab animals for the safety of the child and the animals.
$
100.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
How did you hear about Wildlife Adventure Club?
*
Previous Summer Camper
Friend
School flyer
Social Media
CWC Website
Google Search
Chintimini e-news
Program at my child's school
OSU Summer Camp Fair
Other
Terms & Conditions
Date & Time of Registration
-
Month
-
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
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