our registration packet

Thanksgiving Break Camp Registration
Child’s Information:
Child’s Full Name (First, Last):
Nickname:
Gender:
Parent/Guardian Information:
Full Name (First, Last):
Full Name (First, Last):
Street Address:
City, State, Zip Code:
E-mail 1:
Primary phone: (
)
Alternate phone: (
)
Alternate phone: (
)
Date of Birth:
Age:
Relationship:
Relationship:
E-mail 2:
Type:
Type:
Type:
Who’s?
Who’s?
Who’s?
CHILD HEALTH FORM
This form must be completed by a parent/guardian for ALL children.
Child’s Full Name (First, Last):
Nickname:
Gender:
Date of Birth:
Age:
Emergency Contacts:
In case we are unable to reach the Parent(s)/Guardian(s) on page 1, who should we contact?
Please provide TWO emergency contacts who are NOT parents/guardians listed on page 1.
Full Name (First, Last)
Phone Number(s)
Relationship to camper
Child Information:
Camper is under the care of a physician for the following conditions:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Current treatment(s) and/or medication(s):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Will camper bring an asthma inhaler to event?  Yes  No
If yes, please complete the Specialized Health Care form.
CHILD HEALTH FORM (page 2)
Immunization History
 Child is fully immunized and all immunizations are current
 Child is partially immunized or some immunizations are
not current
 Child is vaccination exempt
Date of Last Tetanus Shot: _______________
Has this child had chicken pox?  Yes  No
If not, has this child received the varicella
(chicken pox) vaccine?  Yes  No
Health Care Providers
Provide names and contact information for primary care physician and any other doctors that may need to be reached in case of an
emergency. Primary care physician/pediatrician information MUST be provided.
Type of Doctor
Primary Care Physician/Pediatrician
Name
Phone Number
Allergies
Allergen
 No known allergies
Reaction
EpiPen prescribed?
N/A
 Yes  No
 Yes  No
 Yes  No
N/A
We cannot guarantee that your child will not be exposed to peanuts/nuts and other allergens.
If you have additional concerns, please call (469) 526-1980.
Dietary Restrictions
 Vegetarian
 Gluten Free
 Vegan
 Lactose Intolerant
 Food Allergy _______________________________________________
 Other ____________________________________________________
Health History
Does your child suffer from any of the following? Explain ALL “yes” answers below. Please provide dates/frequency.
Ear Infections
Frequent Colds
Hypertension
Mononucleosis
Hayfever
Penicillin Allergy






Yes
Yes
Yes
Yes
Yes
Yes






No
No
No
No
No
No
Reaction to Poison Ivy
Diabetes
Insect Stings
Bleeding Disorder
Food/Other Allergies
Asthma






Yes
Yes
Yes
Yes
Yes
Yes






No
No
No
No
No
No
Cramps
Psychiatric Treatment
ADD/ADHD
Heart Disease
Epilepsy/Seizures
Other (describe below)






Yes
Yes
Yes
Yes
Yes
Yes






No
No
No
No
No
No
Comments/Dates: __________________________________________________________________________________________
__________________________________________________________________________________________________________
Special Needs
Are there any physical, mental, psychological, or behavioral conditions that require medication, treatment, special restrictions, or
consideration?  Yes  No
If yes, please share information about your child’s mental, emotional and physical health that will enable us to better serve them.
Please describe any strategies you’ve found effective in addressing each need. This information will be stored in a locked file cabinet
and only shared with Audubon staff working during the event.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
I certify that the information provided on the Camper Health Form is true and accurate.
Parent/Guardian Signature: __________________________________________________
Date: ______________
MEDICATIONS FORM
This form must be completed by a parent/guardian for all campers bringing ANY medication to this event. This includes nonprescription medication, such as vitamins, homeopathic, and herbal medicines.
Child’s Full Name (First, Last):
Nickname:
Gender:
Prescription medication must be in the labeled original container by the pharmacist or prescriber.
DO NOT pre-dispense, place in a daily pill holder, wrap in outer materials, or ask us to dispense by other than doctor’s orders.
Please be specific with any variation or conditions association with “as needed.”
Non-prescription medication must be in the original container with printed instructions for use. Non-prescription medication includes
vitamins, homeopathic, and herbal medicines.
All medications (with the exception of asthma inhalers) will be kept in the possession of Audubon.
Dosage
As Needed
Reason Taking
Other
Medication
Check the appropriate boxes
below for each medication.
Afternoon
Please list all medications that your child will bring to camp.
This includes asthma inhalers, EpiPen, over-the-counter and non-prescription drugs.
Lunch

Age:
Breakfast




Date of Birth:
Copy this page as needed for additional medications
Parent/Guardian Signature: __________________________________________________
Date: ______________
Pick-Up Authorization:
Please list ALL persons authorized by you to pick up your child from camp, including parents, grandparents,
siblings, baby sitters, etc. First and last name must be provided as well as phone numbers and relationship.
Full Name (First, Last)
Phone Number(s)
Relationship to Child
ALL PERSONS LISTED MUST BE AT LEAST 18 YEARS OR OLDER. CHILD WILL NOT BE RELEASED FROM CAMP
UNTIL ADULT HAS SHOWN STATE ISSUED PHOTO IDENTIFICATION. IDENTIFICATION MUST BE SHOWN EVERY
DAY. PLEASE BRING I.D. IN FOR PICK UP. PLEASE INFORM ALL PERSONS LISTED ABOVE OF THIS PROCEDURE IN
ADVANCE.
If YES, please list names:
_______________________________________________________________________________
Parent/Guardian Signature: __________________________________________________
Date: ______________
GENERAL INFORMATION
Please retain this document for your convenience.
Completed registration packets may be returned to:
Mail or in person:
Dogwood Canyon Audubon Center
ATTN: Michaela Kral
1206 W. FM 1382
Cedar Hill, TX 75104
Hours: Tues-Sun 9:00a-5:00p
E-mail:
[email protected]
Please send all documents in one PDF
package.
Fax:
(972) 291-6430
Contacts:
Registration Questions: Michaela Kral, Administrative Assistant – [email protected] – (469) 526-1987
Camp Questions/Contact: Dogwood Canyon Audubon Front Desk- (469) 526-1980 (between the hours of 9:00am-5:00pm)
Melissa Paschke, Senior Education Manager –cell phone (561) 302-7650 (before 9:00am and after 5:00pm)
What Audubon Provides:
 First aid kits
 2 snacks daily (morning, afternoon)
What to Bring:
 Wear clothing suitable for outdoor activities
 Hiking boots or other sturdy CLOSE-TOED shoes suitable for slippery and rugged trails – CLOSE-TOED SHOES ARE REQUIRED
 Extra change of clothing (just in case)
 Reusable Water bottle
 Sunblock
 Insect repellant
 Camera (optional) – No cell phones
 Small amount of money (optional). There will be time for campers to visit the gift shop. There are items ranging from 25
cents and up.
Do NOT Bring:
 Cell phones
 Electronics
 Jewelry
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Trading cards
Other valuable items
Electronic games
Parent Responsibilities
Fill out all registration forms completely
Read all communications distributed to parents regarding Camp
Make alternate arrangements if your child is ill.
Keep the staff informed of any changes or incidents in the home which might result in a change
in behavior or attitude.
Parents must sign their child in and out of the program daily.
Listen to concerns of the staff regarding their child and, with staff, work out an agreeable
solution.
Parent should feel free to discuss any concerns with the staff at Dogwood Canyon Audubon.
Apply sunscreen on your child at home BEFORE attending camp. You may provide sunscreen
for your child, but staff is not allowed to directly apply sunscreen to campers.
Parent/Guardian Signature: __________________________________________________
Date: ______________
Camper Expectations:
Parents, please review with your child(ren) our expectations of campers to make their time with the
program a pleasurable experience. Expectations will be posted so campers can refer to them. Rules
and consequences will be reviewed regularly.
 Campers must remain in the designated camp/program areas.
 Campers are expected to exercise respect towards all people, places of business, equipment,
others private property, vehicles, and nature.
 Campers are expected to follow the rules associated with activities and program areas and ask
a staff member for clarification, if needed.
 Campers are expected to communicate and conduct themselves in an appropriate manner.
Threatening words, tones of voice, gestures, foul language, teasing, bullying, harmful physical
contact will not be tolerated and are prohibited.
 Parents/guardians are financially responsible for their child’s actions when the participant:
o Defaces and/or destroys the building, grounds, equipment, vehicles or other’s
belongings
o Tampers with or pulls the fire alarm without due cause
In order for all participants to have a safe and enjoyable experience, all participants must demonstrate
appropriate behavior and respect for themselves as well as others. Meeting this expectation will offer
all campers and staff the greatest opportunity for success. Campers may be dismissed from camp,
without a refund, if the guidelines within this packet are not followed.
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Camper Check-In and Check-Out
Campers will start and end their days in the Trout Lily Room.
Upon arrival for drop off, please allow sufficient time to park your car and walk up your child(ren) to
the Trout Lily Room.
You may drive into and park in the circular drive, but do not leave your car running and please take
your keys with you.
All children need to be signed in/out each day and parents must have a picture ID on them and be on
the authorized pick up list.
Anyone designated to pick up your child must be at least 18 years of age or older.
Identification
All parents, guardians, and friends (approved to pick up children at the end of the camp day) MUST
show a picture ID in order to pick up the child. This policy is for all parents, guardians and friends, and,
for the safety of your child. No exceptions will be made from this policy. Parents need to know that we
will not release a child to a parent without an ID, no matter how well we know parents or guardians.
Camp staff has the right to refuse dismissal of campers to any person not listed or coherent at pick up.
Parent/Guardian Signature: __________________________________________________
Date: ______________
Late Pick Up
Campers must be picked up by 3:00pm (Monday and Tuesday) and 2:00pm (Wednesday) if pre/post
care is not purchased. If pre/post care is purchased, campers must be picked up by 6:00pm (Monday
and Tuesday) and 3:00pm (Wednesday).
Camp staff works very hard during the day, and often has commitments they must attend to after
work, so please be prompt when picking your child up from camp. A late fee of $25 per child will be
assessed on your family account for the camper picked up 1 to 10 minutes beyond the scheduled pick
up time. A fee of $1.00 per minute/per child will be assessed every minute beyond the first 10
minutes. Your child(ren) will not be able to return to the program if the late fee is not paid within 24
hours of late notice.
Illness:
Keeping our campers healthy is of great importance. If your child becomes ill while at camp, you will
be notified immediately to pick up your child. For the protection of all campers and staff, do not bring
your child to camp if they have a temperature of 100.4 degrees or higher, are vomiting, have
diarrhea, drainage of the eye, green drainage of the nose, or any contagious disease that your child
has been exposed to or infected with (chicken pox, mumps, measles, strep throat, pink eye, etc.) If
they have been ill, we ask that they are symptom free for 24 hours before bringing them back to camp.
We will call the parents of a child if they have any of the above symptoms.
 A camper who becomes ill or has a temperature of 100.4 degrees or more while in camp will be
separated from program participants but will remain within supervision of the staff. A parent
will be notified and required to pick up their child within two hours of notification.
 When campers at the camp have been exposed to a communicable disease listed in the
Department of Health’s current communicable disease chart, the parents shall be notified in
writing within 24 hours or the next business day of the camp, unless forbidden by law, except
for life threatening diseases which much be reported to the parents immediately.
Parent/Guardian Signature: __________________________________________________
Date: ______________
NATIONAL AUDUBON SOCIETY RELEASE OF LIABILITY AND USE OF IMAGE
BY PARTICIPANT IN DOGWOOD CANYON AUDUBON CENTER PROGRAM
LANZAMIENTO DE RESPONSABILIDAD Y USO DE IMAGEN DEL PADRE/GUARDIAN DEL HIJO PARTICIPANTE
Participant’s Name/Nombre del Niño: _____________________________________________________________________________
Participant’s Gender/Género: ________________
Participant’s Date of Birth/Feche de Nacimiento: _________________________
Date of Program/Feche de Programa:
November 21-23, 2016
Name of Program/Nombre del Programa: Thanksgiving Break Camp
As the person, or parent and/or legal guardian of the Participant named above, I wish to or for my child to participate in National Audubon Society’s
(“Audubon”) Program identified above (“Name of Program”). I understand there are possible dangers associated with the Program, including but not
limited to poisonous plants, biting and/or stinging insects, animals, adverse weather conditions, transportation to sites, etc. I understand that
participation in the Program may involve sustained physical activity. I and/or my child is in good health and I am aware of no physical problem or
condition that will limit or interfere with the ability to participate in the Program. I agree that I and/or my child is participating in the Program at my
own risk, and acknowledge that Audubon has made no warranty or representation, expressed or implied, regarding the safety of conducting the
Program.
I agree and understand that photographs, and/or video which include my or my child’s image, taken at the Program may be used in Audubon’s
publications for Audubon’s advertising, publicity, commercial or other business purposes. I hereby give Audubon permission to duplicate and
distribute the photographs/video, or any parts thereof which include my or my child’s image, in perpetuity in any manner and in all media, including
the Internet, whether now or hereafter devised. I waive any right to inspect or approve the finished version(s).
I expressly release and hold harmless Audubon and its officers, directors, employees, agents, licensees, successors, and assigns from and for any
and all claims, demands, actions, and causes of action whatsoever on account of any loss, damage, or injury to person or to property suffered or
incurred by me or my child, except by Audubon’s negligence, in connection with the Program or any aspect of it, including, but not limited to, any
transportation arranged by, paid for, or provided by Audubon.
This release shall be binding upon me, my heirs, next of kin, executors, administrators, and assigns. By signing below, I acknowledge that I have
thoroughly read and understood this form and that the statements I have made are all true.
Como padre/guardian legal del niño indicado arriba, deseo que mi hijo participar en el programa de al Sociedad Nacional Audubon, Inc. (“Audubon”
identificado arriba como el “Programa”), que incluirá programas en la clase y experiencias al aire libre. Entiendo que hay peligros asociados con el
Programa, incluyendo pero no limitado al contacto con plantas alergicas, insectos que pican, animales, condiciones meteorológicas adversas,
transportación a sitios, etc. Entiendo que la participación de mi hijo puede incluir actividad fisica sostenida. Mi hijo está en buena salud y no estoy
conciente de cualquier problema fisico o condición que limitará o va a intervenir con la capacidad de su participación en el Programa. Estoy de acuerdo
que la participacion de mi hijo es a nuestro propio riesgo y reconozco que Audubon no ha hecho ninguna garantia o representación, actual o implicada,
sobre la seguridad de conducir el Programa.
Estoy de acuerdo y entiendo que las fotografías y / o video que incluyen mi imagen o el de mi hijo, tomada en el programa podrán usarse en las
publicaciones de Audubon para la publicidad de Audubon, fines de negocios comerciales o de otro tipo. Por la presente autorizo a Audubon de
reproducir la apariencia, nombre, imagen, semejanza, voz y información biográfica en conección de mi hijo con el Programa de cualquier y todo modo,
incluyendo materiales promocionales y alguna y todos los medios incluyendo el Internet, a tráves del mundo y en perpetuidad.
Libero expresamente a Audubon, sus oficiales, directores, empleados, agentes, concesionarios y sucesores, y asignantes de alguna y cualquier
reclamación o causas de acción que yo tenga o pueda tener por (i) difamación, invasión de privacidad, o derecho de publicidad que resulte del uso
del Centro Audubon de la apariencia, nombre, semejanza, voz y información biográfica, incluyendo pero no limitado a, la distribución, emisión o
exposición de eso o (ii) debido a cualquier pérdida, daño sufrido por persona o propriedad o incurrida por mi hijo, excepto por la negligencia de
Audubon, en conección con cualquier aspecto de la participación de mi hijo en el Programa o en cualquier actividad relacionada con el Programa,
incluyendo cualquier tipo de transportación pagado o proporcionado por Audubon.
Esta liberación será obligatoria sobre mí y mis herederos, familiares más cercanos, ejecutores, administradores y asignantes. Al firmar debajo,
reconozco que he leido la forma o fondo y entiendo sus contenidos, y todas las declaraciones que he hecho son verdaderas.
Parent or Guardian Signature/Firma de Padre o Guardián: ______________________________________________________
Print Name/Nombre en Letra: _______________________________________ Date/Feche: ___________________________
Street Address/Dirección: ________________________________________________________________________________
City, State Zip/Cuidad, Código Postal: _______________________________________________________________________
ONE-TIME CREDIT CARD PAYMENT AUTHORIZATION FORM
Sign and complete this form to authorize National Audubon Society, Inc. dba Dogwood Canyon Audubon Center to make a one-time
debit to your credit or debit card listed below.
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is
permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your
account.
Please complete the information below:
I, __________________________________________________________(FULL NAME), AUTHORIZE
NATIONAL AUDUBON SOCIETY, INC. DBA DOGWOOD CANYON AUDUBON CENTER
TO CHARGE MY CREDIT CARD ACCOUNT INDICATED BELOW FOR
$_______________ ON OR AFTER___________________.
THIS PAYMENT IS FOR THANKSGIVING BREAK CAMP.
Billing Address
______________________________________
Phone#________________________
City, State, Zip
_____________________________________
E-mail
Account Type:
Visa
MasterCard
________________________
AMEX
Cardholder Name
_____________________________________________________
Account Number
_____________________________________________________
Expiration Date
_________________
Security Code
_________________ (3 digit code on back of card)
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined
above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for
one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit
card company, so long as the transaction corresponds to the terms indicated in this form.
SIGNATURE
DATE