Summer education application

Parent or Guardian Name *

First

Last

Parent or Guardian Cell Phone Number *

Parent or Guardian Home Phone Number *

Please indicate which phone number is your preferred contact in case of emergencies *

Cell phone Home phone Other (fill in below)

Other phone numbers *

Relationship to student *

Parent or Guardian Email *

Parent or Guardian Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Information

Student pick up

Please list all adults authorized to pick student up from program. Include full names and relationship to student *

Note: Students will not be released to adults not included on this list. So if your child may need to be picked up by a relative or neighbor, please identify them here.

Student Health Insurance Information

Policy Holder's Name *

First

Last

Policy Holder's Employer *

Health Insurance Provider *

Insurance Policy Number *

Please scan a copy of your health insurance card, both front and back, and upload it using the box below. File may be uploaded as a PDF, JPG, or .Docx.

Policy Holder's Relationship to Student *

Employers Address *

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Line 2

City

State

Zip Code

Country

Special Needs

Are there any physical, mental, psychological, behavioral, or dietary conditions requiring special restrictions or considerations which we should be aware to ensure your student’s fullest enjoyment? Please describe, including any special accommodations necessary. Please note that it is your responsibility to supply any necessary medical equipment which relates to a specific medical condition. Please describe any and all considerations and special needs in the box below. If necessary, additional information can be included by sending an email to education@huyckpreserve.org

Liability Waiver

I hereby give permission for my student's participation in any and all activities associated with the summer education program I am registering my student for, Nature Study or the Natural History Day Program (hereafter Summer Ed Programs). I acknowledge that there are known-inherent and unforeseeable risks in these activities. The known-inherent risks of activities my student will participate in are: dangers associated with interaction with nature, natural forces, swimming and other strenuous outdoor activities, and the possible loss of personal property and injury due to personal actions. I do hereby waive, release, and absolve the Edmund Niles Huyck Preserve, Inc., its past, present, and future directors, officers, employees, and agents (whether acting as agents for the Huyck Preserve or in their individual capacities) from any and all claims arising out of injury or other harm to my student during their participation in Summer Ed Programs at the Huyck Preserve and further agree to indemnify and hold harmless the Edmund Niles Huyck Preserve, Inc., its past, present, and future directors, officers, employees, and agents from any claims, actions, expenses, or other damages arising out of that participation as well as arising out of any actions of my student.

Consent for Medical Treatment in Case of Emergency

I hearby consent and authorize Huyck Preserve staff to seek medical treatment for my student as they see necessary. I consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care subsequently deemed necessary by a licensed health care provider. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care, and that it is given to provide Huyck Preserve staff authority to seek medical treatment, and to provide a licensed health care provider the authority to administer this treatment as s/he judges necessary to my student. I accept responsibility for payment of all services rendered; I authorize any medical facility which renders services to release medical information necessary for the processing of insurance claims; and I authorize the payment of insurance claims directly to the medical facility. I understand that whenever possible, Huyck Preserve staff will make a good faith effort to contact me before seeking treatment. If this is not possible, I understand that Huyck Preserve staff will notify me or my designee as soon a possible of any and all diagnoses and treatments.

Application for Summer Education Programs

2017 Summer Education Program Application

Parent/Guardian Information

Student Information

Student pick up

Student Health Insurance Information

Special Needs

Liability Waiver

Consent for Medical Treatment in Case of Emergency

Photo Release

Pay Online!

Nature Study

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