EarthWays Center Program Information and Material List

Size: px

Start display at page:

Download "EarthWays Center Program Information and Material List"

Marilynn Pearson
5 years ago
Views:

1 EarthWays Center Program Information and Material List Thank you for registering for classes at the EarthWays Center. It is important that you retain this form in addition to the confirmation of registration form that was ed (or mailed) to you as proof of registration upon arrival. Materials Needed: Arrival: Please arrive at least 10 minutes early so that you can check in and take care of personal details. We know you appreciate our beginning on time! Location of Classes: Most classes initially meet at the EarthWays Center, located in midtown St. Louis on Grandel Square just north of the Fox Theatre. Parking & Transportation: Metered parking is available at EarthWays Center. Meters need to be fed along Grandel Square until 7 p.m. on week days and Saturday and, beginning April 1, until 10 p.m. (20 min. per quarter). Please bring quarters. Accessibility: The EarthWays Home, a historic structure, is not wheelchair accessible. Please contact (314) prior to the date of the class if you need special accommodations. Inclement Weather: Participants should come dressed for the weather as classes are usually held rain or shine. If we are unable to hold a class due to inclement weather, we will notify you that a class has been canceled. For questions, please call the EarthWays Center at (314) Cancellations/Refunds: For cancellations 5 or more business days prior to the class, a full refund (minus a $5.00 processing fee) will be issued. Refunds cannot be issued for missed classes or cancellations less than 5 business days or missed classes. Many classes will allow you to send an alternate participant if you are unable to attend. Please contact the EarthWays Center at (314) prior to sending an alternate. EarthWays Center, a division of the Missouri Botanical Garden, is located at 3617 Grandel Square in Grand Center, the arts and entertainment district of mid-town St. Louis. From i-70, exit Grand, go south, then right on Grandel Square. From i-64/us 40 and i-44 exit Grand, go north, then left on Grandel Square. Attention: Grand Boulevard is slated to be closed in both directions between Chouteau Ave. and the I-64/40 Ramp starting June Visit for the latest directional information and confirmation on the Grand Boulevard closure.

2 EDUCATION PROGRAM PARTICIPATION FORM FOR A MINOR PLEASE send this form to: Missouri Botanical Garden / Education Division P.O. Box 299, St. Louis, MO Child s Name (Please print) Educational Program(s) attending (Please print) Parent or Guardian s Name and Telephone Number (include work, home and cell) (Please print) SECTION 1: PARTICIPATION AUTHORIZATION FOR A MINOR The Missouri Botanical Garden s Education Programs may visit several different areas located on the main grounds of the Missouri Botanical Garden or its other sites (collectively referred to as Garden ). While qualified and First Aid/CPR certified staff will supervise students and normal safety precautions will be observed, we must have your written permission for your child to participate in these activities. Activities may include: hiking, walking, exploring, and sleeping in and around these habitats - gardens, woodlands, prairies, ponds, and playing group initiative games. The child named above has my permission to participate in these activities and field programs at the Garden. I have had the opportunity to inspect the facilities and equipment that will be involved in the Education Program and feel that it is in the best interest of my child to participate in this Education Program. SECTION 2: ADULT CHAPERONE AUTHORIZATION For your child s safety, please list the name and phone number of any person(s) other than yourself who may be dropping-off, chaperoning or picking up your child while participating in the Education Program at the Garden. The Child must arrive and depart with you or their designated adult chaperone and will not be released from the Education Program to anyone (other than you) not listed below and presenting the proper identification. The adults named below have my permission to drop-off, pick-up and/or chaperone my child. Name Name Phone Number Phone Number SECTION 3: MEDICAL INFORMATION Please understand that the following information is vital for our staff to know in order to make wise decisions regarding the well being of your child. Name: Birth date: / / Last First M.I. (Month/day/year) Address: City: State: Zip: Male Female Name child prefers to be addressed as: Parent or Guardian: Relationship: Phone Number: Home ( ) - Cell ( ) - Business ( ) - Page 1 of 4 Revised 03/10/10sg BC approved 3/1/10

3 Child s Name (Please print): If we cannot reach you, whom can we notify? Phone Number: Home ( ) - Business ( ) - Family Physician: Office Number: ( ) - Is this youth insured under a family health insurance policy? No Yes if yes, provide the following: Health Insurance Company: Policy Holder s Name: Policy Number: Group Number: Member ID: Insurance Phone Number: Health History (Check appropriate items and give approximate date where applicable) Bronchitis Constipation Sore throats Convulsions Frequent Colds Stomach upsets Diabetes Headaches Other: Ear Infection Hypertension Epilepsy Hypoglycemia (low blood sugar) Fainting Sinusitis Any known respiratory difficulties or allergies? (Please list reaction time if known.) Animal Fur Asthma Bee or Insect Stings Foods (specify) Any physical limitations? (Please describe) Hay Fever Penicillin Poison Ivy, Oak, Sumac Other Please list and describe any conditions currently being treated and/or medications currently being taken. Any special dietary requirements? Any tips for helping your child learn or feel comfortable in a new social setting? The information provided in this form is not subject to the protections of The Health Insurance Portability and Accountability Act (HIPAA) of 1996 or other federal health care laws. **PLEASE EXPLAIN ANY ADDITIONAL CONCERNS OR RESTRICTIONS USE A SEPARATE SHEET IF NECESSARY AND ATTACH IT TO THIS FORM. Page 2 of 4 Revised 03/10/10sg BC approved 3/1/10

4 Child s Name (Please print): SECTION 4: MEDICATION AUTHORIZATION This section must be fully completed for any child to take prescription and non-prescription medications while enrolled in the Garden s Education Programs. The Garden s policy requires that all students who need medication during our Education Programs must do the following: 1. Present this form signed by a parent or legal guardian. 2. Bring the medication in the original prescription bottle, properly labeled by a registered pharmacist as prescribed by law. Non-prescription medications should be in original labeled containers. Please check appropriate response. My child will be responsible for holding onto and administering his/her own medication. Please fill out the following for medication to be received during an Educational Program. Name of medication Specific time(s) Dose(s) I would like a staff member to hold on to my child s medication and remind her/him to take it at the appropriate time. I give permission for my child to receive the above medication as directed. SECTION 5: PHOTO RELEASE I hereby authorize the Garden or its agents to take, archive and produce photographs, film, videotape, digital and other images and/or audiotape or other recordings ( Images ) of my child and any property in my child s possession or under his/her control. I further authorize the Garden and its agents to use the Images, now or at any time in the future, in newspapers, magazines, journals, websites, commercials and other marketing or informative materials and any other publication or medium print, electronic, video or otherwise in whatever ways it considers desirable in its communications, archival and/or other efforts. SECTION 6: INDEMNIFICATION, RELEASE AND WAIVER In order to induce the Garden to permit my child s participation in the Education Program, I hereby certify that the following statements are correct and true and I represent and warrant the same, where applicable. 1. My and my child s participation in the Education Program is entirely voluntary. I am of lawful age and capacity to execute this form and in particular, this Indemnification, Release and Waiver ( Release ). I understand the risk of injury and hazards inherent in the Education Program, and I expressly agree to assume such risks and hazards. 2. I understand that this Release shall be governed by the laws of the State of Missouri without regard to its choice of law principles. 3. I and my child will participate in the Education Program only at such places and in such a manner as instructed by the Garden but in addition shall use our own best judgment to be healthy, safe and uninjured during the Education Program. I agree to notify the Garden of any health or safety hazard, accident or injury existing or occurring in whole or in part during, or in whole or in part related to, the Education Program and will fully cooperate with the Garden with respect to any health or safety hazard, accident or injury inquiries and provide the Garden with any information related thereto. 4. I, on behalf of myself, my child and other heirs, my executors and administrator and anyone claiming through me or my child, do hereby forever release, remise and discharge the Garden, its directors, officers, employees, volunteers, independent contractors, agents, representatives, successors and assigns, ( Covered Persons ) from and against, and hereby waive, all claims, rights, demands, causes of action, liabilities, damages, losses, costs, or expenses, including reasonable attorneys fees, interest, fines or penalties in connection therewith, whether known or unknown, foreseeable or unforeseeable, at law or in equity ( Claims ), which may be sustained by me or my Page 3 of 4 Revised 03/10/10sg BC approved 3/1/10

5 Child s Name (Please print): child by reason of property (tangible or intangible) damage or loss, accident, personal injury, death, health impact or otherwise (collectively, Injuries and individually Injury ), resulting from, arising out of, or relating to the Educational Program or any other interaction with the Garden or any other Covered Person, whether such Injuries result from the negligence, willful act or omission or strict liability of me or my child, the Garden or any other Covered Person. I hereby assume complete responsibility for (i) any Injury to myself or my child and (ii) any, if caused in whole or in part by me or my child, Injury to any other person or entity, and loss or damage to my, any such other person s or entity s, or the Garden s, property that may occur in connection with my participation in the Education Program. 5. I further agree to indemnify, defend and hold harmless the Garden and the Covered Persons from all Claims which they incur and/or to which they may be subjected resulting in whole or in part from, arising in whole or in part out of, or relating in whole or in part to, my and/or my child s participation in the Education Program or other interaction with the Garden or any Covered Person. I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD AND I VOLUNTARILY ACCEPT THE TERMS AND CONDITIONS STATED HEREIN. I UNDERSTAND AND ACKNOWLEDGE THAT I MAY BE GIVING UP SUBSTANTIAL RIGHTS BY SIGNING BELOW. I FURTHER UNDERSTAND AND ACKNOWLEDGE THAT THIS RELEASE SHALL BE EFFECTIVE AND BINDING UPON ME AND MY CHILD AND ANYONE CLAIMING THROUGH US AND EFFECTIVELY BARS OUR RIGHT TO CLAIM DAMAGES OF ANY KIND INCLUDING INJURIES OR EVEN DEATH ARISING FROM THE ACTIVITY. SECTION 7: MEDICAL RELEASE I understand that parts of the Garden Education s Program may be physically demanding. I affirm that the youth named below is in good health, and that he/she is not under a physician s care for any condition that might endanger his/her safety or the safety of other participants, or in any way limit his/her ability to participate in any of the Education Program activities for which he/she is registered. I grant permission to the Education Program instructors or Garden staff to secure medical aid and/or hospital services deemed necessary for the individual named on this form, in the event he/she should sustain an injury or illness while participating in the Program. I authorize emergency medical responders and the doctor and hospital to which my child may be brought to perform any emergency procedure or operation, to give treatment, injections, and the administration of any anesthetic to my child. I have indicated any medical information which the Education Program instructors, Garden staff or a medical treatment provider may wish to consider in treating any illness or injury sustained by my child in the course of participating in the Education Program. Signature: Date: Printed Name: Address Phone I, a witness, eighteen years of age or older, observed the above-named person voluntarily, and with apparent good understanding and mental capacity, signing above. Witness Signature: Address Name: Phone Page 4 of 4 Revised 03/10/10sg BC approved 3/1/10

6 H O W T O F I N D U S... I 70 I 370 Missouri River I 170 Butterfly House I 64/40 Clarkson Olive I 270 EarthWays Center I I 44 Missouri Botanical Garden Mississippi River I 55 Shaw Nature Reserve M I S S O U R I B O T A N I C A L G A R D E N B U T T E R F LY H O U S E E A R T H WAY S C E N T E R S H AW N AT U R E R E S E R V E» Going east on Interstate 44, exit at Vandeventer and turn right, then left at Shaw Boulevard.» Going west on Interstate 44, exit at Vandeventer and turn left, then left at Shaw Boulevard.» From Highway 40, take Kingshighway south to Vandeventer and turn left then right at Shaw Boulevard. Take I-64/40 west to Clarkson Road/Olive Boulevard exit. Turn right onto Olive Boulevard. Two miles ahead, Faust Park is on the left Olive Boulevard Chesterfield, MO (636) From I-64/40 or I-44, take Grand North past the Fox Theatre. Turn left on Grandel Square at Powell Symphony Hall Grandel Square Grandel Square St. Louis, MO (314) The Shaw Nature Reserve is 22 miles west of the I 44, I 270 junction. Take exit 253 off of I 44 and follow the signs. Hwy. 100 & I-44 (exit 253) Gray Summit, MO (636) M I S S O U R I B O T A N I C A L G A R D E N 4344 Shaw Boulevard St. Louis, MO (314)

WRAP/YMCA Expanded Learning Program

WRAP/YMCA Expanded Learning Program 2018-2019 School Year School: Child s Last Name: First Name: Sex: M F Birth date: / / Age: Home Phone: ( ) Home Address: Cell Phone: ( ) City: State: Zip: Child lives with: Mom Dad Both Parents Other Begin