Spring 2020 After-School Enrichment Registration Form
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Child's Name (First & Last) *
Child's School and Day *
Child's Grade *
Child's Teacher *
Parent's Name *
Parent's Cell Phone Number *
Parent's Alternative Phone Number
Parent's Email *
Anyone Else Authorized to Pick Up My Child *
NATURE CLUB Session(s) Attending *
Required
DISCOVER CLUB Session(s) Attending *
Required
Payment *
Required
Membership Information *
Emergency Contact other than Parent/Guardian (name, relationship, phone) *
We want to care for your child well.  Please let us know if your child has ANY medical or behavioral conditions. *
Does your child take any medications? If so, please indicate the medication (over-the-counter or prescription) *
After Nature Club or Discover Club ends at 4:30, my child
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I will allow DNS to use pictures of my child in promotional material. *
Parental Release Agreement - By typing your name below you agree to these terms. I have been advised of and/or recognize the risk inherent with my child’s participation in this program. I assume full responsibility for all injuries that may arise from his/her physical or emotional limitations.  I unconditionally release DNS and its employees from any and all liability or claims that may result from his/her participation in this program, unless the injury or damage is primarily the direct result of negligence of DNS or any of its employees and not caused in part by my child’s own negligence. This child has no health, emotional, or injury-related conditions (recent or chronic) which will be aggravated by or which will exclude his/her active participation in the program. This child has seen a physician in the last year. In case of injury or illness, I give permission for my child to be transported to and receive medical treatment at a local medical facility, and I guarantee the payment of all expenses incurred for such transportation and treatment. *
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