Nature’s Nursery

Child's First Name: *

Child's Last Name: *

Parent's Email: *

Parent/Guardian's First Name: *

Parent/Guardian's Last Name: *

Phone Number: *

Child's Grade Level (no exceptions to intended grades, please): *

Child's Age (again, no exceptions please): *

Alternate Phone Number (in case of emergency): *

Do you allow your child to be photographed and/or videotaped by White Memorial Staff? Media may be used in future publicity efforts (including Facebook and our website): * Yes No

Any applicable allergies (nature-related, food, or otherwise)?: *

Any other medical or behavioral issues we should be aware of?: *

The White Memorial Conservation Center requires that children attending this program be up to date on all State of CT vaccinations, or submit the necessary exemption documentation. Is your child up to date on their vaccinations?: * Yes No

If you selected "No," in order for your child to attend this program, please provide us with the required exemption documentation prior to the program start date. Completed forms should be mailed to WMCC, Attn: Lois, P.O. Box 368, Litchfield, CT 06759. To obtain the necessary forms, contact the State of CT Dept. of Public Health or visit https://portal.ct.gov/DPH/immunizations/immunizations-exemptions-certification-forms...Thank you: I understand.

How did you hear about this program?: A flyer distributed to school Word of mouth "Habitattler" weekly email "Sanctuary" newsletter Our website During another program A newspaper or other external marketing source

If you selected "a newspaper or other external marketing source" in the last checklist, please tell us which one: