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General Information

Participant's name:
*

Date of birth:
*

Gender:
*

Grade (Grade Entering for Summer Camps):
*

School:
*

Are you an ECHO member?
*

If yes, please list your membership number:

E-mail Address:

How did you hear about ECHO Camps?

First Guardian

Name:
*

Relation:
*

Primary phone:
*

Secondary phone:

Second Guardian

Name:

Relation:

Primary phone:

Secondary phone:

First Emergency Contact

Name:
*

Phone:
*

Second Emergency Contact

Name:
*

Phone:
*

My child will walk home:
*

My child may go home with (in addition to guardians and emergency contacts):

Name:

Name:

Photo Release

By checking this box, I authorize ECHO Lake Aquarium and Science Center at the Leahy Center for Lake Champlain (“ECHO”) to use the above named person’s image for ECHO related printed and digital materials, without limitation, as ECHO shall in their sole discretion determine. This authorization is without date restriction. ECHO agrees that this photograph will not be given or sold to any individual or organization and will only be used for ECHO promotional purposes. If the above named person is a minor, ECHO further agrees not to use the name of the above mentioned person in relation to the use of the photograph unless the Parent/Guardian signs the applicable release line below.

Minor Person Appearing Name Usage Release

By checking this box, I hereby grant ECHO the right to use the name of the above mentioned Minor Person in relation to the photograph, for ECHO related printed and digital materials, without limitation, as ECHO shall in their sole discretion determine.

Liability/Transportation Waiver

* By checking this box you are indicating your understanding that ECHO assumes no responsibility for any injury suffered by your child as a result of his/her participation in ECHO programming either on or off ECHO premises, and, that neither you nor your child, nor the heirs, administrators, executors, and assigns of either shall ever institute, or aid in the institution of any action at law or otherwise against ECHO on account of any injury to your child or his/her property resulting from his/her program participation, and/or you and your child, for your selves and your heirs, administrators, executors and assigns HEREBY RELEASE ECHO, its Board of Governors, Trustees, Officers, employees and agents from and against any and all claims for personal injuries to your child or loss of or damage to his/her property arising out of his/her activities as a ECHO program participant.

Further, I authorize the staff of the ECHO to take my child/ward on field trips involving vehicular transportation, boating, paddling, swimming, and cycling.

Medical Information/Release

Food or other allergies:

Physical limitations (asthma etc.):

Special dietary requirements:

Other special needs:

Do you give us permission to dispense medication that you provide?

Name of medication‡:

Purpose of medication:

Dosage:

Time needed:

Special instructions:

Warning signs of condition:

Possible reactions/side effects:

‡Medication must be provided in its original packaging and include the prescribing physician's contact information.

* By checking this box, I authorize the staff of the Lake Champlain Basin Science Center, Inc. D/B/A ECHO Lake Aquarium and Science Center at the Leahy Center for Lake Champlain (ECHO) to carry out standard first aid and CPR, including treatment of severe allergic reactions, and to arrange for emergency care for my minor child/ward at a local hospital, as the staff deems necessary. I authorize hospital personnel to provide emergency medical treatment for my child/ward.

 

©2014 LCBSC - ECHO Lake Aquarium and Science Center/Leahy Center for Lake Champlain - One College St. - Burlington VT 05401 - 1.877.324.6386
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