Day-Off Camps

Participant Information
Participant's Name*
First Last
Date of Birth*
Children must be 5 years of age or older to participate in this program.
Month
Day
Year
Is this child currently enrolled in the "Wild Wanderers" after-school program?*
If yes, we will refer to the emergency contact and medical history information and waivers that you recently provided.
- Yes, please refer to the information that I recently provided.
- I will complete that information on this form.
School Name*
Grade*
Child's Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Day-off Program Selection
Programs which have reached capacity will no longer appear on the list below.
Please select the dates you would like your child to attend.*
(Program dates which have reached capacity will not appear on the list below.)
- Select All
- Friday, November 1
- Tuesday, November 5
- Monday, November 11
- Monday, December 2

Medical Information and Permissions
List all important allergies or health conditions. Please enter a response for each or type "none".
Allergies*
Please list the allergen and reaction
Health or Medical Conditions*
List any conditions that our staff should be aware of.
Special Needs*
Does your child need special assistance or accommodations.
Regular Medications*
List any medication your child takes on a regular basis.
Medical or Dietary Information, In Case of Emergency*
Such as dietary restrictions or concerns.
Does your child require one-on-one support in a school setting?*
- yes
- no
One-on-one support policy agrement*
Children who require a one-on-one aide in a school setting are required to have an adult aide with them at camp. The Schuylkill Center is not able to provide staff for one-on-one support. By checking the box below, you agree that you understand and agree to arrange and provide this support.
- Yes, I agree and will arrange my child's one-on-one support for camp.

Physician Contact Information
Physician Name*
First Last
Physician Phone*
Office or Clinic Name*
Physician Address*
Street Address City State ZIP Code
Child's Health Insurance Provider:*
Child's Health Insurance Policy Number:*
I give staff permission to administer the following to my child:
- Sunscreen
- Insect Repellant
- Benedryl
- Tylenol

Waivers
Liability Waiver
In providing high-quality education and care for your child(ren), we consider you a partner and ask for your support and cooperation in the stated policies and procedures below.
You agree to your child being present when animals, plants and other native wildlife are brought in by Schuylkill Center experts for lessons. You agree to the medication policies, illness procedures, and emergency plan and notification guidelines as outlined in the Registration form and waiver statement. You understand that Schuylkill Center employees are mandatory reporters of any suspected incidence of child abuse or neglect and are required to follow state guidelines in reporting such incidents.
You understand the mission and goal of the Schuylkill Center is to inspire meaningful connections between people and nature. Through Schuylkill Center camp programs, your child will be provided the opportunity to develop by learning to take risks, judge their limits, and practice responsibility both in our classroom and outdoor space. Every reasonable precaution will be taken by the school and staff to prevent serious accidents and injuries. However, you understand the implied risk of exploring outdoors and you will not hold the Schuylkill Center, Schuylkill Center staff, or other parents liable for accidents.
In signing below, you (the parent) recognize that the activities at the Schuylkill Center for Environmental Education may involve physical and outdoor activity and grant permission for your child to participate in all activities of the camp program. In consideration of the Schuylkill Center allowing your child to participate in its activities, you assume all risks and hazards incidental to such participation, including risk of serious injury to the child, and do hereby waive on the child’s behalf and on behalf of yourself and other relatives of the child, any and all claims relating to such participation against the Schuylkill Center, its Board, employees, organizers, volunteers and other participants. The Schuylkill Center or its representative has your permission, in an emergency where you cannot be located immediately, to transport your child at your expense to the emergency room of the nearest hospital. The hospital and its staff have your permission to provide treatment which is deemed necessary for the well-being of your child.
By checking this box and signing electronically below, I acknowledge that I have read and agreed to all terms above.*
- Yes
Electronic Signature*
I grant The Schuylkill Center for Environmental Education permission to use video, still images, and/or quotes of myself or my child in internal Schuylkill Center publications such as newsletters and classroom documentation.
Hidden
By checking this box and signing electronically below, I acknowledge that I have read and agreed to all terms above.*
- Yes
- No
Electronic Signature*
I grant The Schuylkill Center for Environmental Education permission to use video, still images, and/or quotes of myself or my child in Schuylkill Center marketing materials such as social media, brochures and advertisements, and professional presentations.
By checking this box and signing electronically below, I acknowledge that I have read and agreed to all terms above.*
- Yes
- No
Electronic Signature*

Participant Information

Day-off Program Selection

Guardian Information

Emergency Contacts

Medical Information and Permissions

Physician Contact Information

Waivers

Liability Waiver

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