Participant name (first, last)_________________________________________________ Age:______
Adult (parent/guardian of participant) name_______________________________________________
Address_________________________City_____________________State________Zip__________
Work Phone______________ Home Phone______________ Emergency name & #_______________
E-mail Address ___________________________________________________________________
Allergies/medical info________________________________________________________________

Register my child for the following units of the Summer Service program:

__ June 25- 29, 9 am-noon (M-F): Unit 1 - Wildlife in the Garden
__ July 9 - 20, 9am-2pm (M,W,F): Unit 2 - Garden Art and Literature
__ July 30 - August 10, 9 am - 2 pm (M,W,F): Unit 3 - Menus and Me
__ August 20-24, 9 am - noon (M-F): Unit 4 - Seed Saving: Planting a Revolution

I have enclosed $______ for Summer Service Program ($12 per unit)

I hereby certify that I am the legal parent or guardian of the child registered 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, board of directors, and employees against any claim, loss, liability or expense including attorney's fees resulting directly/indirectly from participation.

Parent/guardian Signature _____________________________________ Date____________________