<p> Sweetbriar Nature Center 62 Eckernkamp Drive, Smithtown, NY 11787 Tel: (631) 979 6344 Fax: (631) 979 9233 www.sweetbriarnc.org ______DISCOVERY WEEKS REGISTRATION AND EMERGENCY CONTACT FORM </p><p>Name and age of child /children attending ______</p><p>Name of Program/s ______</p><p>Dates attending and days of aftercare ______</p><p>Parent/Guardian Name ______</p><p>Address (including town and zip code) ______</p><p>______</p><p>Primary Phone Number ______Secondary Number______</p><p>Emergency Contact and Phone Number______</p><p>E-mail address ______</p><p>List all persons INCLUDING YOURSELF who have permission to pick up your child. ______</p><p>Allergies or medical conditions we should know about should be listed below.</p><p>______Payment Information (All checks made out to Sweetbriar Nature Center)</p><p>Form of Payment (Check one): Cash_____Check_____Credit Card______</p><p>Type of Credit Card(circle one): Mastercard Visa </p><p>Name on credit card______Member Y N Would like to become one</p><p>Credit Card # (3% handling fee) ______</p><p>Amount______Security #______Expiration Date______</p><p>If you would like to become a member please include $35 for a family membership. I give my child ______, age______permission to attend the Sweetbriar Nature Center discovery programs both on and off Sweetbriar grounds including field trips where outside transportation is required. I will be responsible for all transportation to and from the discovery camp site. I will provide a bag lunch and snack for my child. I am familiar with and recognize the risks associated with my child’s participation in an outdoor program that involves walking through woodlands and field, and exploring near rivers, ponds, marshes, and off site bus trips. Furthermore, I know of no reason why my child cannot attend an indoor/outdoor program. I, also, grant permission for Sweetbriar Nature Center to obtain emergency medical treatment for my child, and agree to be fully responsible for all costs of such treatment, and upon my request prior to or during camp to have staff aware of any medications that my child requires. Lastly, I give Sweetbriar permission to use any photographs taken of my child/children for promotional purposes. FINAL PAYMENT SHOULD BE RECEIVED BY JUNE 30.</p><p>Parent Signature______, Date______</p><p>T-SHIRT SIZE (Summer Only) (Check one)</p><p>Small ______Medium ______Large ______</p><p>Cancellation Policy</p><p>Sweetbriar Nature Center reserves the right to cancel a Discovery Week session due to insufficient enrollment. If Sweetbriar cancels a session, all fees will be fully refunded. If you remove your child from a Discovery week session before it begins, membership fees are non-refundable and the refunds are as follows:</p><p># Days Before Session Non-Refundable Begins Amount 21+ 50% of camp fee 20- 14 75% of camp fee 13-0 100% of camp fee Sorry, we cannot make exceptions</p>