Wildlife Images Rehabilitation & Education Center

Registration Information:

Registrant Name: *

Birthdate: *

Ages 6-11 Only

Grade: *

Medical Information: *

Please list any medical conditions, allergies, special considerations or dietary issues, etc. we should be aware of. Due to the nature of the programming, facility, and staffing, Wildlife Images regrets it may not accept students who are medically fragile, or on an IEP. Ineligibility for programming is at the discretion of Wildlife Images staff. Requests for special accommodations will be considered on a case-by-case basis with prior notice so we can discuss how to best accommodate your camper’s needs.

Guardian Name & Relationship to Registrant *

Guardian Telephone: *

Guardian Email: *

Participant Release Form: *

I am the participant’s (named above) parent or legal guardian. I represent to WIREC that I have the authority to execute this release, and that I will hold WIREC harmless from any and all claims or demands that may arise from this release. I hereby authorize the teacher, supervisor, or designated representative of WIREC to either call emergency services or transport and admit my child to a medical facility and arrange for my child to be provided with emergency treatment by a licensed physician. I fully understand & accept that my child & I are not covered by any insurance pertaining to Wildlife Images, or guaranteed medical payment coverage which would compensate should I or my son/daughter be injured. I fully release, discharge, and hold harmless forever, Wildlife Images, its corporation officers, board of directors, staff, & volunteers, from all things, acts, omissions, and conditions which may cause me or my child, injury or any other problems.

Restrictions & Requirements *

I have read and understand the Homeschool Workshop Handbook, including the cancellation and refund policy.

Image Release: *

I hereby give my permission for images of my child, taken during Wildlife Images (WIREC) activities through video, photo and digital camera, to be used for the purpose of WIREC’s promotional material and publications, and waive any rights of compensation or ownership there to.

Who, other than yourself,
is authorized to pick up your child from the facility?

Name:

Relationship To Registrant:

Name:

Relationship To Registrant:

Name:

Relationship To Registrant:

Emergency Contact Information:

We will contact the parent or guardian first. This should be a secondary emergency contact in case we cannot contact the guardian.

Emergency Contact: *

Phone Number: *

Relationship To Registrant: *

Payer Information:

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address. If you do not receive a receipt, your registration did not go through. Please contact education@wildlifeimages.org for assistance.

How did your hear
about us?

Your Payment Information:

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *