One-Day Fun Day Grades 1-3 2021

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): *

Parent/Guardian's Full Mailing Address: *

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 applicable medical or behavioral issues?: *

The White Memorial Conservation Center requires that children attending this program be up to date on all State of CT required immunizations, or submit the necessary exemption documentation. Is your child up to date on their immunizations?: * 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.

COVID Consent Statement: Everyone participating in this program, whether vaccinated or not, will need to wear a mask that covers their mouth and nose indoors and when we are not socially-distanced outdoors. No person who has shown symptoms indicative of a virus within 10 days of a program will be allowed to participate (unless COVID has been ruled out as the cause through a negative test result). No person who has tested positive for COVID within 14 days of a program will be able to participate, regardless of symptoms. No person who has been in the same household as, or has been in contact with (within 6 feet for 15 minutes or more), someone who has tested positive for COVID/displayed indicative symptoms within 10 days will be able to participate. I acknowledge that failure to comply with the aforementioned regulations will result in dismissal from the program, with no refund being issued. I also acknowledge that White Memorial reserves the right to cancel a program(s) with little to no advanced notice as a result of a change in governmental guidelines. A refund will be issued in this case. I understand that I cannot hold White Memorial liable, nor can any member of my household, if someone shows symptoms of, or tests positive for, any contagious diseases, including COVID.: * I understand.