Name: Living Labs SES Grades 2-4 Magical Mushrooms
Start: 2024-10-01T15:50:00-04:00
End: 2024-10-01T17:30:00-04:00
Location: Wahaneeta Preserve

Parent/Guardian Name

Phone

Email

Student's Name

First

Last

School

Grade

Authorized Pick Up: NAME, RELATION, PHONE.

Students will only be released to caregivers listed here.

Bus Transportation Home

Yes
No (student will be picked up at 5:30 PM at WLT location)

Primary Emergency Contact: NAME, PHONE

Secondary Emergency Contact: NAME, PHONE

Medical History

List any medical and/or allergies. If participant has a known medical condition/allergies and is prescribed a medication (i.e. EpiPen, inhaler) the medication and/or 2 EpiPens MUST be brought to program and be on their person.

Does your child have an IEP?

Yes
No

Bus Drop Off Address

Address Line 1

City

State

Zip Code

LIABILITY WAIVER

I agree to the additional terms.

In consideration of receiving permission to participate in (educational) (volunteer) (recreational) opportunities of the Westerly Land Trust (WLT), I (legal guardian if a minor):
1. Understand and acknowledge that I am proceeding at my own risk. I understand that WLT makes no warranties or representation, expressed or implied, regarding the condition or safety of the property itself or the activity to be done.
2. Agree to release, hold harmless and indemnify WLT (including its agents, employees and service volunteers) from any loss, liability or expense with respect to bodily injury (including death) or property damage which might result from or arise of my participation in these activities.

PHOTO RELEASE

Yes
No

WLT and our partners may use photos/recordings to promote future programs. I (legal guardian if minor) grant WLT permission to use any and all photographs and/or recordings taken at this event for publicity and promotion.

STAY UP TO DATE ON OUR EMAILS

Yes
No

The Westerly Land Trust

Living Labs SES Grades 2-4 Magical Mushrooms

Tuesday October 1st @ 3:50 pm - 5:30 pm

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The Westerly Land Trust

Living Labs SES Grades 2-4 Magical Mushrooms

Tuesday October 1st @ 3:50 pm - 5:30 pm

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