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Nature Club Fall 2020

PERMISSION FORM, MEDICAL and COVID-19 WAIVER and PAYMENT

Please fill out this form, even if you had previously completed one for the past school year. We like to keep our records up to date in case of any changes.  

**One form per child, per program is required**

***Please provide us an email address that you routinely check - it is what we will use for program communication***

Thank You! 

Participant Information
Please fill out this form for each of your children if you have multiple participating in programs.
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Authorized Guardian
Please list anyone that will be picking up your child. If you need someone other than the people listed below to pick up your child you must notify the Staff member in charge. Any party, including those listed below, that picks up a child must have a photo ID available.
Parent / Guardian Contact Information
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Emergency Contact
(if we are unable to contact guardians listed above, please contact)
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Medical Information
We want your child to have a positive experience. If there is anything we need to be aware of to make this possible please list below and call FERN HOLLOW NATURE CENTER at 412-741-6136 to discuss.
Medical Conditions
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Does your child have any of the following conditions?
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Emergency Waiver and Authorization
This health history is correct as far as I know. I understand that participation in Nature Discovery Camps is completely voluntary. I understand that the staff and volunteers of FHNC will make every effort to ensure the safety and health of each participant but there are certain risks for physical injury in any outdoor program, and agree to assume full risk of any injury which might occur as a result of participation in Fern Hollow Nature Center activities, and will not hold FHNC or its staff and volunteers responsible. In the event of an emergency, I hereby give consent to authorize personnel to administer emergency treatment to my child, including hospitalizations, securing proper treatment including but not limited to x-rays, injections, anesthesia, and/or surgery. I understand that any medical expenses will be billed directly to me or my insurance company.
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UNACCEPTABLE BEHAVIOR CLAUSE
Fern Hollow Nature Center (FHNC) expects children to be well mannered, attentive, and respectful to others. The fun and safety of others will not be jeopardized by bad behavior (i.e. physical or verbal abuse, bullying, malicious and willful destruction of property, failing to abide by the camp rules, etc.) FHNC reserves the right to remove your child from said activities or remove your child from the camp if the problem continues without a refund. A copy of the Camp Rules has been sent as an attachment to you via email.
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Illness
If your child becomes ill or illness is detected, we will call parents and/or contact to have child picked up. Keep your child home if your child has a rash, eye infection, is coughing, has shortness of breath, or sore throat, had a fever in the last 48 hours, had a new loss of taste or smell, had vomiting or diarrhea in the last 24 hours.
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Photo and Public Relations Release
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Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue
NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read this document carefully and in entirety. By signing this agreement, you give up your right and the named minor’s right to bring a court action to recover compensation or obtain any other remedy for any personal injury or property damage however caused arising out of the named minor’s participation in Fern Hollow Nature Center programs and activities at its physical locations or through electronic or online means, now or any time in the future.
Acknowledgment of Risk
I, in my legal capacity as the parent/guardian of the minor named above, do hereby acknowledge and agree that participation in Fern Hollow Nature Center programs and activities comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with participation either in person at its physical locations or through electronic or online means, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with participation in Fern Hollow Nature Center programs and activities participation and that said list in no way limits the operation of this Agreement.
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Coronavirus / COVID-19 Warning & Disclaimer
Coronavirus, COVID-19, is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in Fern Hollow Nature Center programs or accessing Fern Hollow Nature Center facilities could increase the risk of contracting COVID-19. Fern Hollow Nature Center in no way warrants that COVID-19 infection will not occur through participation in Fern Hollow Nature Center programs or accessing Fern Hollow Nature Center facilities.
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Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of the above-named minor's participation in Fern Hollow Nature Center programs and activities, I, the parent/guardian of the minor named above, agree to release and on behalf of myself and the minor named above, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE Fern Hollow Nature Center, its officers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, the named minor, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against Fern Hollow Nature Center on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to the use of theFern Hollow Nature Center facilities/equipment or participation in Fern Hollow Nature Center programs whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees.
In consideration of the named minor’s participation in Fern Hollow Nature Center programs and activities, I, the undersigned parent/guardian of the named minor, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to the named minor’s participation.
I hereby certify on behalf of myself and the named minor that I have full knowledge of the nature and extent of the risks inherent in Fern Hollow Nature Center program and activity participation and that I, on behalf of myself and the named minor, am voluntarily assuming said risks. I understand that I and the named minor will be solely responsible for any loss or damage, including personal injury, property damage, or death, the named minor sustains while participating in Fern Hollow Nature Center programs and activities and that by signing this agreement I, on behalf of myself and the named minor, HEREBY RELEASE Releasees of all liability for such loss, damage, or death. I further certify that the named minor is in good health and has no conditions or impairments which would preclude his/her safe participation in Fern Hollow Nature Center programs and activities.
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PA Department of Health Statement on Travel *updated 8/23/20
If you have traveled, or plan to travel, to an area where there are high amounts of COVID-19 cases, it is recommended that you stay at home for 14 days upon return to Pennsylvania. If you travel to the following states, it is recommended that you quarantine for 14 days upon return: Alabama, Arkansas, California, Florida, Georgia, Idaho, Kansas, Louisiana, Mississippi, Missouri, Nevada, North Dakota, Oklahoma, South Carolina, Tennessee, Texas.
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Electronic Signature
By writing my name below, I certify that I have read the above information. My signature also certifies my understanding of and agreement with the above policies. The information provided is correct to the best of my knowledge.
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First Name
Last Name
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(mm/dd/yyyy)
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PAYMENT
Nature Club Fall 2020 Registration Fee.
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First Name
Last Name
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Contact email