Summer education application

Application for Summer Education Programs

This application is for our summer youth education program --- Nature Study. Please complete all required fields and submit the application. Payment is required prior to the start of the program and may be done online with credit or debit card or in person via cash or check. For more information on the program visit the program pages: Nature Study, Natural History Day, Wildlife Ecology Research Day.

Below you will find the Registration, Health Insurance, Liability Waiver and Medical Consent, for the Huyck Preserve's summer education programs: Nature Study, Natural History Day, and Wildlife Ecology Research Day.

Parents/Guardians please complete and sign where indicated the Registration, Health Insurance, and the Liability Waiver and Medical Consent Form. Additionally, please provide a copy of your health insurance card (front and back).

A registration form should be completed and submitted for each student registering for any of our summer education programs.

If you have any questions about summer education programs at the Huyck Preserve or the registration process, please do not hesitate to contact us by email (info@huyckpreserve.org) or phone (518-797-3440).

2018 Summer Education Program Application

* Indicates required field

Select the Program for which you are registering a student *

2018 Program Dates
Nature Study (K - 2nd): July 9-13
Nature Study (3rd - 5th): July 16-20
Natural History Day (6th - 10th): July 23 - 27
Wildlife Ecology Research Day (11th - 12th): July 30-Aug. 10

Parent/Guardian Information

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 Name *

First

Last

Student Date of Birth *

Grade student is entering in September *

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. If your child may need to be picked up by a non-parent/guardian, please identify that person here.

Student Health Insurance Information

Primary Care Physician Name *

First

Last

Is the student covered by your health insurance plan? *

Yes No

PCP Phone Number *

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 *

Line 1

Line 2

City

State

Zip Code

Country

Upload Health Insurance card *

Max file size: 20MB

Special Requirements

Does your child have any restrictions or considerations that we should be aware of to ensure his/her fullest enjoyment of the program? Please describe these below, 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.

Comment *

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, Natural History Day, or Wildlife Ecology Research 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.

Enter Today's Date *

Name *

First

Last

Check here to confirm you have read and agree to the Liability Waiver statement *

I agree

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.

Enter Today's Date *

Name *

First

Last

Check here to confirm you have read and consent to medical treatment in case of emergency *

I consent

Photo Release

I give permission to the Edmund Niles Huyck Preserve, Inc. to use my student’s photo in publications, on its website, or other presentations to the general public. *

Yes No

Submit Application

Pay Online!

After you submit your application, don't forget you can pay online with your credit or debit card. To do so, return to the Nature Study, Natural History Day Program or Wildlife Ecology Research Day Program pages and go to the cart at the bottom of the appropriate page. Please note: to receive Preserve member pricing, you will see instructions to stop by the office or send your payment in the form of a check to the Preserve.

Application for Summer Education Programs

2018 Summer Education Program Application

Parent/Guardian Information

Student Information

Student pick up

Student Health Insurance Information

Special Requirements

Liability Waiver

Consent for Medical Treatment in Case of Emergency

Photo Release

Pay Online!

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