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EMNC Program Registration Form
Endless Mountains Nature Center
P.O. Box 536, Tunkhannock, PA 18657 * 570-836-3835

To register for programs:
1. Print this page.
2. Complete form, including Emergency Medical Release, if applicable.
3. Calculate registration fee.
4. Make check payable to "Endless Mountains Nature Center."
5. Mail form and check to EMNC.

Name:_______________________________________________________________________________
Phone:______________________________________________________________________________
Address:____________________________________________________________________________
City, State, Zip:___________________________________________________________________
Email:______________________________________________________________________________

Program Title:______________________________________________________________________
Program Date:___________________________
Number of Adults:_____
Number of Children:_____
Fee for program:________


Program Title:______________________________________________________________________
Program Date:___________________________
Number of Adults:_____
Number of Children:_____
Fee for program:________



Emergency Medical Release for Unaccompanied Minors

     I, the undersigned, hereby give permission for my child, _____________________________, to participate in the above activities of the Endless Mountains Nature Center and assume all risks and hazards incidental to the program(s). I also hold harmless Endless Mountains Nature Center, its staff, and appointed assistants.

     I fully consent to emergency medical care to be rendered by licensed medical personnel should my child require it and I cannot be contacted. I consent to emergency transportation, if necessary.


__________________________________________
Parent/Legal Guardian Signature


________________
Date