Forest Bound Application

Name*

First Last

Email*

Please use the email that you would like to use to correspond with coordinators.

Phone*

Age*

Ethnicity*

For grant reporting purposes only

I identify my gender as:*

What city do you live in?*

I currently attend:*

If you currently attend school, what is the name of your school?

I am applying for:*

Please choose the session you are applying for: Sessions are Monday - Friday (9am drop off, 3pm pick up).

Please check which classes you have completed?*

Select All
Language arts
Earth Science
Biology
AP Biology
Chemistry
AP Chemistry
Physical Education

Please describe your level of experience with botany and / or native plants. Have you taken any classes covering plant anatomy and physiology, botany courses? Can you identify any native plants? etc.

What are your academic areas of interest?*

Please outline any specific assistance you may need during the program:*

FIELD TRIP RELEASE FORM: Name of participant*

The participant is attending the session in:*

The following special health problems should be noted and adequate precautions taken (list such items as unusually severe reaction to bee stings, other severe allergies, hemophilia, diabetes, heart disease etc.)*

The following medication, prescriptions or special diets are needed:*

In the event of an accident or illness, I understand that reasonable effort will be made to contact the parent immediately. However, if I am not available, I authorize Forest Bound Educators to secure emergency medical care if needed.*

Yes
No

Name of Preferred Doctor & Phone Number:*

Name of Insurance Carrier & Phone Number:*

Primary Contact:*

Best phone number to contact:*

Secondary Contact & Phone Number:

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM*

Forest Bound Participant Name

The participant / guardian provides consent to have the participants photo taken during the summer program.

Photos are used on the IAE website, and in other publications/education materials to promote the program. Photos are not used for anything other than Forest Bound materials.

This activity provides a learning experience for the students and allows them an opportunity to apply their classroom learning. Although I understand that the Forest Bound Program will make reasonable effort to provide a safe environment, I am fully aware of the special dangers and risks inherent in participating in the activity. Being aware of those risks, I hereby give consent for the participant listed in this release form to participate in the activity. My signature reflects my knowledge of the details of the trip and the itinerary. I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING AND /OR VOLUNTEERING IN THIS ACTIVITY OR EVENT, and waive, release and discharge the Institute for Applied Ecology and their directors, board members, officers, employees, volunteers, agents, representatives or assigns and the activity or event sponsors, from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may occur to me as a result of participation in the above named activity at the School Facility. I agree to indemnity, hold harmless, and promise not to sue the entities or persons mentioned above from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of those released or otherwise. This accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.*

Please have parent read and sign if under 18 years of age. Please type name:

Intent to E-sign*

I read and agree with the following intent to e-sign:

By checking this box, I agree that this form may be electronically signed, and that my e-signature holds the same validity, enforceability, and admissibility as my handwritten signature.

Parent Signature (if under 18):*

Forest Bound Deposit*

Price: $30.00

In order to ensure your space with this awesome program, we ask for a 100% refundable deposit of $30. This will be refunded to you on the first day that the student attends the Forest Bound Program. If you are unable to attend the program for any reason, you are able to receive your deposit back up two weeks prior to the program. If you do not notify us at least two weeks prior to the first date of the program, your deposit will not be refunded.

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name