Virtual Winter Nature Story Time

GUARDIAN Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:

• Fee

  Type	Fee
  Event fee	$10.00

CHILD Information

• * Child First Name:
• * Child Last Name:
• * Child Birth Date:

ADDITIONAL CHILD Information

You may add a maximum of 5

Photo Release/Release of Liability

• Photo Release: I do hereby consent and agree that Winnie Palmer Nature Reserve and its employees, or agents have the right to take photographs, videotape, or digital recordings of the child(ren) indicated above and to use these in any and all media, now or hereafter known, and exclusively for the purpose of Winnie Palmer Nature Reserve. I further consent that my name and identity may be revealed by descriptive text or commentary. I do hereby release to Winnie Palmer Nature Reserve and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration.

• Name of person giving consent.

• I do hereby agree to the photo policy and agree to have the child(ren) in my care photographed.

  • Yes
  • No
• Relationship to child(ren)