Discovery Camp

Discovery Camp Registration Form
Program ID*
Select Service

After-School (4206)Free Adult/Family (4070)Museum Sleep-In (4210)Paid Adult/Family (4120)Pre-K (4208)Vacation (4204)Discovery Camp (4212)Exploration Camp (4214)Wonder Camp (4216)
Service Schedule Name*
Staff Email
example@example.com
Camp Acknowledgements

Yes
Add Transport Permission Acknowledgement

Yes
Program Fee (per week - members)*
Program Fee (per week - nonmembers)*
Registration Start Date for NON-Members

MonthDayYear
Date
Week 1 Start*

MonthDayYear
Date
Week 1 End*

MonthDayYear
Date
Week 2 Start

MonthDayYear
Date
Week 2 End

MonthDayYear
Date
Week 3 Start

MonthDayYear
Date
Week 3 End

MonthDayYear
Date
Week 4 Start

MonthDayYear
Date
Week 4 End

MonthDayYear
Date
Enter title & program description here....
{ProgramTitleDescription}

Pricing:

Member	${FeePerWeekMember}
Non-Member	${FeePerWeek}

Are you an active member?*

YesNo
Would you like to add a membership or renewal to your cart today?*

Family Membership ($60.00)Individual Membership ($40.00)Do Not Add Membership
Please Note: To receive the member rate on children's programs, you must maintain a Family Membership.
Non-Member Block?

Yes
Sorry! Registration for non-members opens on April 15th. To sign up early, you may purchase a family membership with your registration today!
Available Weeks
Sorry! Camp registration is currently limited to one week per participant.
No dates have been selected. Please note: even if there is only one date left, you must select the checkbox to complete the form.
Participant
Participant's Name*

First NameLast Name
How Many Attendees Total (including yourself)
YOUR Name*

First NameLast Name
Are you the child's parent or legal guardian?

YesNo
Your Information

(complete if you are not the child's guardian)
Your Relationship to the Child
Your Email
example@example.com
Your Preferred Email
Your Primary Phone Number
Please enter a valid phone number.
Your Preferred Phone
Your Mailing Address

Street Address

Street Address Line 2
CityStateZip Code
Parent/Guardian Contact Information
Parent/Guardian Name

First NameLast Name
Email*
example@example.com
Preferred Email
Primary Phone Number*
Please enter a valid phone number.
Preferred Phone
Mailing Address

Street Address

Street Address Line 2
CityStateZip Code
Child's Information
Child's Birthdate*

MonthDayYear
Date
Entering Grade Level (in the fall)*
Alternate Phone Number to Call in Case of Emergency During Program*
Please enter a valid phone number.
Do you allow your child to be photographed and/or videotaped by White Memorial Staff? Media may be used in future publicity efforts (including on Facebook/Instagram and our website).*

YesNo
We require that children attending this program be up to date on all State of CT required immunizations, or that you submit the necessary exemption documentation. Is your child up to date on their immunizations?*

YesNo - if no, please email a waiver signed by a physician
Please select which of the following topical products (if any) you allow White Memorial Staff to apply/re-apply:*

Bug Spray that does NOT contain DEETBug Spray that DOES contain DEETSPF 50 Sunscreen SprayHand SanitizerNone of the Above
Does this child have applicable allergies (food, nature-related, or otherwise)? If not, leave blank.
Are there other medical or behavioral issues we need to be aware of? If not, leave blank.

Acknowledgements/Permissions
In this program, we often transport children, both on and off White Memorial property, via a 15 passenger van (equipped with seatbelts) driven by White Memorial staff. I give permission for my child to be transported.

I agree
Refunds will only be issued (minus a $20 service fee) if a cancellation is made at least 2 weeks in advance of the first day of the camp you're booking.

I understand
You will receive a follow-up email requesting that you submit the necessary forms for registration. Your child’s space will now be held, but the registration process is not complete until the necessary forms are filled out and returned.

I understand
Signature
PLEASE NOTE:
White Memorial staff is not permitted to stock any medications. This includes inhalers, Epi-pens, Tylenol, or topical medications such as Neosporin, calamine lotion, Benadryl, etc. White Memorial’s Nature Camp does not have a nurse, but our staff has been trained to administer first aid, as well as oral, topical, inhalant, and epinephrine medications. We also have a relationship with an on-call physician, Dr. Sahl at Hartford Healthcare Pediatrics in Litchfield.

SIGNATURE REQUIRED
I, the undersigned, hereby give permission for the child listed above to participate in all activities (unless otherwise specified) and assume all risks and hazards incidental to the program. I agree to indemnify and hold harmless White Memorial Conservation Center, its staff, and appointed assistants for any injury or accident to this child. I also give permission to the staff of White Memorial to provide and seek emergency medical treatment should an incident arise. In the event I cannot be reached in said emergency, I give permission to the hospital and/or physician selected by White Memorial to administer treatment, including hospitalization at the most accessible location. Transportation to the hospital could be provided by ambulance, a White Memorial vehicle, or a personal vehicle driven by a camp leader. All of the information above is accurate and has been filled out by me personally.
Signature*

Clear
Payment
I would like to make a donation to White Memorial!
Donation Amount

I would like to cover the credit card fees
Credit Card Fees
White Memorial’s Cancellation and Refund Policy for Public Education Programs:

Public education programs are defined as those in which customers register and purchase tickets as individuals. Public education programs are listed on White Memorial's Calendar of Events. Please notify White Memorial of all cancellations as soon as possible so that those "spots" can potentially be opened for other customers. Email info@whitememorialcc.org or call 860-567-0857 to report cancellations.

When a single education program costs under $10 per ticket, payments are non-refundable at any point. For programs (exclusive of Discovery and Exploration Camp) that cost over $10 per ticket, refunds will be issued upon request by the customer if the request is made at least 48 hours in advance of the program. Any refund requests made within 48 hours, or anytime after the program, will not be granted. A $20 administrative fee (per ticket) will be retained by White Memorial for any tickets costing $40 or more. Please email info@whitememorialcc.org or call 860-567-0857 to request a refund.

For Discovery Camp and Exploration Camp, refunds will be issued (minus a $20 administrative fee per child) if a cancellation is made at least two weeks prior to the first day of the camp your child is enrolled in. Refunds will not be issued for any cancellations made less than two weeks from that first day.

If White Memorial needs to cancel a program for any reason, refunds will automatically be issued to all customers. However, please email info@whitememorialcc.org or call 860-567-0857 if you would like your payment to be retained as a donation to White Memorial. We would be very appreciative!

Thank you.
For questions or concerns, please email kelly@whitememorialcc.org.
Sorry! Camp registration is currently limited to one week per participant. You cannot submit this form until you scroll up and reduce your selections to only one week.
Membership Purchase Amount*
Final Program Purchase Amount*
Membership + Program + Donation Amount
Payment Fees Covered by Customer*
Final Payment Due
Donation Amount (converted to #)
Weekly Fee (member/non-member)
Number of Weeks Chosen
Total Weekly Fees
Payment Fee Percentage*
Service Delivery Quantity
Purchased a Membership

TRUE
Received Member Pricing

TRUE
Week 1 Chosen

TRUE
Week 2 Chosen

TRUE
Week 3 Chosen

TRUE
Week 4 Chosen

TRUE
Non-Guardian Name

First NameLast Name
Chose Week: Start Date

MonthDayYear
Date
Archived Fields
Should be Empty:

	First Name	Last Name	Mobile Phone Number
1
2
3

Discovery Camp Registration Form

Available Weeks

Participant

Your Information

Parent/Guardian Contact Information

Child's Information

Acknowledgements/Permissions

Signature

Payment

Credit Card

Archived Fields