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Avery House Nature Center and Naturescaping Registration Form

Please fill out, sign and deliver to Corvallis Environmental Center along with payment and deposit in mail slot
or mail to PO Box 2189, Corvallis, OR 97339. For more information, please call 753-9211 or visit our website at:
http://www.corvallisenvironmentalcenter.org

Name:__________________________________________________Age (if child) _____
Name of parent/guardian (if registering a child) ____________________________________
Address: ________________________________________________________________
City: ________________________________ State: _____________Zip:______________
Work Phone: ____________________________Home Phone: _______________________
Emergency Phone:_________________________Email:_____________________________

Program: _____________________________________Date:______________Fee:_______

Program: _____________________________________Date:______________Fee:_______

Allergies/Medical Info:______________________________________________________________________
Total Fees:______________

How did you find out about our programs?: ___ P&R Ad ___ GT Calendar ___Mailing ___School Flier ___E-mail ____________Other

I hereby certify that I am the legal parent or guardian of the child listed above. I understand and assume the risks of participation in this program. For myself, my heirs and assigns I agree to waive, release and forever discharge any claim for injury or damage, and hold harmless the Corvallis Environmental Center, its officers agents and employees against any claim, loss, liability or expense including attorney's fees, resulting directly/indirectly from participation.

Signature:___________________________________Date:________________