Potomac Valley Audubon Society · Fall 2022 Wee Naturalist

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Parent/Guardian Contact Information

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Email *

Verify Email *

Parent/Guardian Phone *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Membership

PVAS Members can opt to receive updates about activities and upcoming events, membership pricing on events, and the satisfaction of knowing their support makes our programs possible.

Are you a PVAS Member?

Yes

No

Thank you!

Joining PVAS is the best way to stay up-to-date on our activities and upcoming events, plus, your member dues support our programs and operations.

www.potomacaudubon.org/support/become-a-member/.

How many children?

Please indicate the number of children you would like to register.

Registrant Information

Relationship *

I am this child's

Parent

Grandparent

Aunt/Uncle

Sibling

Other Guardian

Child's Name *

First Name

Last Name

Birth Date *

(mm/dd/yyyy)

Who Else May Pick Up Child/Children?

Phone

Who Else May Pick Up Child/Children?

Phone

Child's Gender Pronouns *

Allergies (Type NO if none) *

Disabilities or Special Needs (Type NO if none) *

Medications Child Currently Takes (Type NO if none) *

#2 Child's Name *

First Name

Last Name

#2 Child's Birth Date *

(mm/dd/yyyy)

#2 Child's Gender Pronouns *

#2 Child's Allergies (Type NO if none) *

#2 Child's Disabilities or Special Needs (Type NO if none) *

#2 Child's Medications Child Currently Takes (Type NO if none) *

#3 Child's Name *

First Name

Last Name

#3 Child's Birth Date *

(mm/dd/yyyy)

#3 Child's Birth Date Copy *

(mm/dd/yyyy)

#3 Child's Gender Pronouns *

#3 Child's Allergies (Type NO if none) *

#3 Child's Disabilities or Special Needs (Type NO if none) *

#3 Medications Child Currently Takes (Type NO if none) *

Emergency Contact

Please name someone besides registering parent/guardian.

Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone *

Emergency Contact's Relationship to Child/Children *

September 9 Monarchs in the Meadow - Session 1 (9:30 a.m. - 11:00 a.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional Child - PVAS member price
$10 - Additional Child - General public price

September 9 Monarchs in the Meadow - Session 2 (1:00 p.m. - 2:30 p.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional child - PVAS member price
$10 - Additional child - General public price

September 30 "Pollinator Power" Session 1 (9:30 a.m. - 11:00 a.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional child - PVAS member price
$10 - Additional child - General public price

September 30 "Pollinator Power" Session 2 (1:00 p.m. - 2:30 p.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$10 - Additional child - PVAS member price
$8 - Additional child - General public price

October 28 "Halloween Hike" Session 1 (9:30 a.m. - 11:00 a.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional child - PVAS member price
$10 - Additional child - General public price

October 28 "Halloween Hike" Session 2 (1:00 p.m. - 2:30 p.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional Child - PVAS member price
$10 - Additional Child - General public price

November 18 "Fun in the Forest" Session 1 (9:30 a.m. - 11:00 a.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional Child - PVAS member price
$10 - Additional Child - General public price

November 18 "Fun in the Forest" Session 2 (1:00 p.m. - 2:30 p.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional child - PVAS member price
$10 - Additional child - General public price

December 9 "Animal Tracks and Trails" Session 1 (9:30 a.m. - 11:00 a.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional child - PVAS member price
$10 - Additional child - General public price

December 9 "Animal Tracks and Trails" Session 2( 1:00 p.m. - 2:30 p.m.)	Quantity
$10 - PVAS member price
$15 - General public price
$8 - Additional child - PVAS member price
$10 - Additional child - General public price

Terms and Conditions

Equity, Diversity & Inclusion Policy

The Potomac Valley Audubon Society (PVAS) does not exclude, deny benefits to, or otherwise discriminate against any service recipient, applicant, program staff, or the public on the basis of race, color, religion, national or ethnic origin, disability, age, sex, gender identity and expression, sexual orientation, political affiliation, or veteran status.

Cancellation Policy

For full cancellation requests by registrants made more than one week prior to a program, participants will receive a refund for half the cost of the program(s) being cancelled. Cancellations made less than a week prior to a program will receive no refunds. We will issue a full refund for cancellations made due COVID-19 or other illness.

PVAS will cancel a program if:

- West Virginia Governor issues a Stay at Home Order or an order restricting group size;
- hazardous weather that would create unsafe road conditions or unsafe conditions for being outside is forecasted;
- a staff member critical to conducting an event is diagnosed with an active case of COVID-19;
- the session doesn’t meet PVAS's registration number minimum.

Registrants will be notified by email of any cancelations by 5:00 p.m. the evening before the program.

If PVAS cancels a program, you will receive a full refund.

*We understand that last minute cancellations might need to happen, but please try to let us know as soon as possible, so that depending on the circumstance, we can open the spot to someone else.

Terms and Conditions Acceptance *

I agree to all of the Terms and Conditions listed above.

Permission to Photo/Video *

Indicate whether you agree to allow PVAS to take and utilize photographic images of the registered individual(s) for the purpose of promotion and publicizing our programs and events.

I agree to use of image.

I do NOT agree to use of image.

Permission to Consume Wild Foods *

I give my child permission to consume wild edible foods such as blackberries, wine berries, cattail, water cress, dandelion leaves, tea made from sassafras roots etc. I understand that my child will be taught to follow the rule that no wild foods can be consumed without permission from a staff member.

Yes

No

Coronavirus/COVID-19 Warning & Disclaimer

PVAS has developed COVID-19 Policies and procedures for program operations based on CDC, state, and local health guidelines. Please review these before agreeing to accept and abide by them at the event you are registering for.

COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in our programs could increase the risk of contracting COVID-19. PVAS in no way warrants that COVID-19 infection will not occur through participation in our programs or accessing PVAS facilities.

COVID Release Acceptance *

I understand the above and assume said risks associated with COVID-19 on behalf of all those I am registering. I have read the PVAS COVID-19 policies and agree that all people I register will understand and agree to abide by these policies.

Release of Liability

Medical

If my child is taking a prescribed medication, I give permission for the staff to administer prescription or over-the-counter drugs that my child must take while at camp. All medications must be in their original container and clearly marked with my child’s name.

If my child needs assistance with sun-screen and/or bug repellent application, I give permission for the staff to help my child apply the product(s) that I have provided.

In the event of an emergency, I understand that every effort will be made to contact the parent/guardian as soon as possible. In the event that neither I nor my emergency contact can be reached, I hereby give permission to the physician selected by the program director to secure proper treatment, including x-rays, hospitalization, anesthesia, surgery or injections of medication for my child.

First Aid

I give permission for the staff to administer basic first aid to a child in need of care. This includes but is not limited to: cleaning cuts, applying bandages, removing ticks, and applying icepacks. All injuries and administered first aid will be recorded and the parent will be notified upon pick-up. If my child is feeling ill or has an injury that the staff members feel I should be made aware of prior to pick up, I understand that I will be called and may be asked to pick up my child from camp.

Release of Liability *

I agree to the above release of liability terms.

Electronic Signature *

Scholarship Donation

We want all children to have a chance to come to Outdoor School no matter their financial circumstances . Scholarships are available for families with financial need.

If you would like to help sponsor a child to attend, you can make a donation here:

Donation

$0 - No thank you

$10

$25

$50

$100

$215 - Full scholarship