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Registration must be completed by Parent/Guardian

A separate registration is required for each child you are enrolling.

Before you begin the registration, you will need:

  • Child's health insurance information
  • Date of child's last tetanus shot
  • Digital copy of 2018 federal tax return (if applying for one week scholarship)

If you have all of the above readily available, this registration form should take you between 8 - 10 minutes to complete.

Eco Explorer Camp Dates

Air Week Dates
Water Week Dates
Land Week Dates
Explorer Information
Child's First Name
Child's Last Name
Child's Gender
Child's Date of Birth
Child's Age
Name of School During 2018-19 School Year
Grade Entering This Fall
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to Child
Street Address
Country
Address Line 1
Address Line 2
Address Line 3
City
State
Postal Code
Home Number
Work Phone
Cell Phone (if different from above)

Medical Treatment Authorization

Complete insurance information is required – all children must have medical insurance to attend Eco Explorer Camp.

In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency, I give my consent to contact Emergency Medical Service provider, and agree to release any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. I understand I am responsible to submit any claims to my health insurance company for reimbursement for any medical services provided.

I understand that, in accordance with Environment Erie program policy, the medication(s) should be given at home before and/or after the program. However, when this is not possible and medications will be brought to the youth program, I agree to read and comply with the provisions outlined in the registration confirmation email relating to the management of medications.

HIPPA POLICY

Please know, Environment Erie honors the privacy of the participants in its program and complies with the national regulations regarding health information.

Health History/Information

Name of child's Physician
Is physician authorization for treatment needed?
Physician Phone
Insurance Company Policy Subscriber's Name
Place of Employment
Policy No.
Group No.
Will the youth need to take any medication during the program?

If YES, please list the specific prescriptions or over-the-counter medications below, reasons for medications, and daily dosages. If any medications change prior to arriving at the program, please provide an updated list upon arrival (All medications will be administered and held by staff during the day).

Medication
Reason(s) for medication
Daily Dosage/Time(s) Taken
Known Allergies
Additional Allergy Information from Above
Other Health Concerns
Additional Health Concerns Information from Above
Date of Most Recent Tetanus Immunization:
/
/
Has youth ever been hospitalized?
Please list any major past illnesses (Contagious and Non-contagious)
Is there anything else in youth's health history that program staff should know?
Does youth have any chronic or recurring illness?
Are there any activities from which the youth should be restricted?
Does the youth have any medical appliances (glasses, contact lenses, orthodonture, etc.)? If yes, explain:
Name of Emergency Contact
Relationship to Child
Emergency Contact's Phone
Name of Secondary Emergency Contact
Relationship to Child
Secondary Emergency Contact Phone

Program Expectations (Please review with camp participant(s))

Children are expected to be respectful and courteous to one another, the camp staff, volunteers, and Environment Erie staff. Behavior that is disruptive to a positive camp experience or that puts the camper, other campers, camp staff and/or volunteers in danger will not be tolerated. Disruptive behaviors and/or failure to abide by guidelines above will be handled as follows; 

  • First occurrence: A verbal warning and discussion with camper of expected behavior at camp, as well as a note given to parent/guardian or authorized person at pick up.
  • Second occurrence: Issue will be discussed with parent/guardian.
  • Third occurrence: If the issue is not resolved, the camper will be withdrawn from camp.

No refunds will be issued if a camper is withdrawn for behavior issues or failure to follow guidelines.

Students will not be permitted to have cell phones or any type of weapon with them at this program. It is advised that campers leave electronic games and music players at home as well. Environment Erie or affiliated staff and volunteers are not responsible for the loss of or damage to these items.

I have reviewed the program expectations with the camper, who agrees to follow these expectations.

Enter initials here to acknowledge:

Media Release

Additionally, I/we authorize Environment Erie personnel to photograph, videotape, and/or audiotape my/our explorer for promotion of the Environment Erie Eco Explorer Camp.

Enter initials here to acknowledge:

Hold Harmless

I, as parent or legal guardian of the registered camper, understand that Environment Erie takes reasonable precautions to ensure that Eco Explorer Camp programs and activities are conducted by qualified personnel in a safe and responsible manner. I further understand that these activities involve certain risks and may include, but are not limited to:

  • Environmental hazards, including weather conditions, trees, plants, animals, insects, and rugged terrain
  • Swimming
  • Boating
  • Biking
  • Wading in creeks or streams
  • Climbing trees

I recognize these risks and agree to accept these risks by allowing my camper to attend Eco Explorer Camp and participate in these programs. I hereby release, indemnify, and hold harmless Environment Erie, their officers, agents and employees from all liability deriving from my camper's presence at Eco Explorer Camp, whether arising from an act or omission, negligent or otherwise, to the fullest extent permitted by law.

Permission is granted for my child to participate and I understand that by signing this form I am voluntarily and knowingly accepting responsibility for my child's participation in all of Environment Erie’s Eco Explorer Camp activities.

Camp Scholarship(Explorership) Request:

There are a limited number of one week camp Explorerships available this year. This is a need-based, first-come-first served scholarship. Financial eligibility utilizing federal poverty guidelines will be determined by both total household income and the number of household members as well as the number of campers attending camp from the same family (if applicable). Supporting documentation to verify the household income and size is required with this registration. If applicable, the name(s) of other sibling(s) attending camp are required as well.

How many people (financial dependents) live in this household?
Annual Household Income
Name(s) of other sibling(s) attending camp
No file selected

Once Explorership eligibility has been determined and camp registration completed, any paperwork associated with eligibility determination will be destroyed to maintain confidentiality.

Payment Options

If not applying for scholarship, payment must be received within one week of online registration date to hold spot for camper(s)).

Please make check payable to: ENVIRONMENT ERIE

Mailing Address: Environment Erie, 301 Peninsula Drive, Suite 5, Erie, PA 16505

Drop Off: 2nd floor of the Tom Ridge Environmental Center

If for any reason you need to cancel your registration one (1) month prior to your camper’s registered date(s) of camp, you will receive a full refund of cost of camp. If you need to cancel your registration two (2) weeks prior to your camper’s registered date(s) of camp, you will receive a 50% refund of cost of camp. If you need to cancel your registration less than two (2) weeks prior to your camper’s registered date(s) of camp, no refund will be made unless your camper’s spot can be filled by another camper.

In the event of an emergency cancellation, campers have a choice between a refund based on the cancellation schedule listed above or a credit toward a future program valued at the tuition amount already paid. Additionally, if a camper leaves due to an undisclosed pre-existing medical condition, chooses to leave voluntarily, or is asked to leave the camp due to misconduct or illegal behavior, there is no refund. 
 

Camp Cancellation Policy

SIGNATURE (electronic) (By providing this electronic signature, I affirm that the information shared on this form is true and correct).

Enter your first and last name here to sign:

CAMP REGISTRATION IS FIRST-ONLINE REGISTRATION RECEIVED, FIRST-RESERVED. WHILE WE WILL MAKE EVERY EFFORT TO KEEP AVAILABILITY UP-TO-DATE, YOUR PREFERRED WEEK MAY BE FULL UPON RECEIPT OF THIS FORM. IF REGISTRATION IS FULL FOR PREFERRED WEEK(S), YOU WILL BE CONTACTED REGARDING ALTERNATE WEEK(S) AVAILABLE. IF NOT ABLE TO ENROLL CAMPER(S) IN ALTERNATE WEEK(S) AND ENVIRONMENT ERIE HAS RECEIVED PAYMENT, YOU WILL BE REIMBURSED THE FULL COST OF CAMP REGISTRATION.