Wee Discoverers Summer Camp 2021 (Ages 4 & 5)

Child's First Name: *

Child's Last Name: *

Please specify which date(s) you are registering for. Options are: July 13, 20, 27, August 3 and 10: *

Age: *

Parent's First Name: *

Parent's Last Name: *

Street Address: *

City/Town: *

State: *

Primary Phone Number: *

Alternate Phone (in case of emergency): *

Email: *

Applicable Allergies (food, nature-related, or otherwise): *

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

Do you allow your child to be photographed and/or videotaped by White Memorial Staff? Media may be used for future publicity efforts: * Yes No

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. This does NOT include Covid vaccinations since they are not available to children yet. 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.

A confirmation letter with more details, along with a permission slip, will be mailed to you shortly. Your child’s space will now be held, but the registration process is not complete until the permission slip is filled out and submitted to us by July 1. Also, we do not allow exceptions to the stated age level ranges: * I understand.

COVID-19 Consent Statement: Your child will need to wear a mask that covers their mouth and nose at all times in order to participate (except during designated mask breaks). You will also need to wear a mask during drop-off and pick-up if you get out of your car or if you're approached in your car by a staff person. No person who has shown symptoms indicative of a virus within 14 days of camp will be allowed to participate (unless COVID-19 has been ruled out as the cause through a negative test result). No person who has tested positive for COVID within 14 days of camp 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-19/displayed indicative symptoms within 10 days will be able to participate. No person who has traveled to a state on CT’s Travel Advisory List within 10 days prior to camp will be allowed 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-19.: * I understand.