SASSAFRAS Earth Education
5 Church Street, Aquinnah, MA 02535
Phone: 508 645 2008
Email: [email protected]
APPLICATION FORMS SUMMER 2016 (3 Pages)
Please check the program weeks of your choice:
o July 5-8: Teen Leadership Training $300
o July 11-15: Summer Basics Week $300
o July 18-22: Survival I Week $300
o $360 with overnight
o July 25-29: Water Week $350
o Aug 1-5: Combo Week $300 per week or o $75 per day
o Aug 8-12: Scout and Track Week $300
o Aug 15-19: Survival II Week $300
o $360 with overnight
Participant Name:
(please use one form per person)
DOB:
Age:
Grade this fall:
_____________________________________________________________________
Name Parent/Adult
Address
Town/State/Zip
Phone Home
Email
___________________________________________________
___________________________________________________
___________________________________________________
_______________________ Cell: _______________________
___________________________________________________
Please take a moment to describe anything about your child, that may be helpful for us to know,
including strong likes/dislikes, strengths, passions and challenging situations.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please, inform us if your child finds paying attention, and functioning in a group challenging.
Please do let us know if your child is enrolled in special educational programs:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
If applicable, check the following for discounts or scholarships:
o 5% Off: I am an Early Bird and will have my paperwork and deposit in by May 1st
o 5% Off: We are an Island Family, living on MV year-round.
o 10% Off: I am signing my child up for 4 weeks (or more).
o 50% Off: We are a Wampanoag Family and would like to receive the discount.
o Scholarship: I want to apply and have included my scholarship form.
Please send all 3 pages (you are on p. 1), a copy of your child’s immunization records, and your
$100 deposit per week (or your payment in full), to the address above. Thank you.
I hereby agree to sign my child/teen/self up for the program checked above and to pay the
corresponding amount,
Signed: ______________________________________
Dated: __________________
SASSAFRAS Earth Education
5 Church Street, Aquinnah, MA 02535
Phone: 508 645 2008
Email: [email protected]
RELEASE FORM
I, __________________________________________ (parent or adult’s name),
herewith give permission for pictures taken of my child(ren) during program times, to
appear on Sassafras’ website and or flyers.
In consideration of the services of Sassafras Earth Education (SEE) and Saskia &
David Vanderhoop, being outdoor programs, concentrating on nature awareness,
primitive skills, and naturalist activities, on and around their campsite in Aquinnah, at 5
Church Street, during the 2016 summer and the 2016/ 2017 school year, for:
_______________________________________________________(participant’s name),
I, __________________________________________________ (adult’s/parent’s name),
Here by agree to release, indemnify, and discharge David and Saskia Vanderhoop and
SEE.
The risks include among other things: Slipping and falling; falling objects; water
hazards; exhaustion; exposure to temperature and weather extremes; which could cause
hypothermia, hyperthermia, sunburn, dehydration, and exposure to potentially dangerous
animals, insect bites; and hazardous plant life; equipment failure; and improper lifting or
carrying.
I promise to accept and assume all of the risks involved in the activities, and hold
David and Saskia Vanderhoop and SEE harmless from any and all claims, demands, or
causes of action, which are in any way connected to participation of myself/my
child/children/grandchild in the activities or any use of equipment or facilities of David
and Saskia Vanderhoop.
Adult/Parents Name:_______________________________________________________
Signature:
Date:
SASSAFRAS Earth Education
Medical Evaluation and Emergency Contact Form
Summer 2016 and School Year 2016/2017
Participants name: ____________________________
Address_____________________________________
Town _____________________ State/Zip __________
Age______ DOB ________
Sex ______
Phone __________________
Parent(s)/Guardian/Adult:_________________________________________________
Address_____________________________________
Phone __________________
Town _____________________ State/Zip __________
Cell ____________________
Email _______________________________________
Cell____________________
________________________
Emergency contact person:
Name _________________________________________ Relation_________________
Address_____________________________________
Phone __________________
Town _____________________ State/Zip __________
Cell ____________________
1. Are you allergic to any of the following and how severe?
Medication (e.g. penicillin, aspirin) ___________________________________________
Foods (e.g. peanuts, shellfish) _______________________________________________
Plants (e.g. poison ivy, nettles) ______________________________________________
Please list any other allergies: _______________________________________________
2. Does your child/you carrry an EPI pen_____________________________________________
Please describe what for, and past experiences__________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.Do you wear contact lenses? _____________ Hearing aid? ____________________________
4. Do you have asthma of any sort? __________ If yes, please describe ____________________
______________________________________________________________________________
5. Do you have high or low blood pressure? Please circle and describe _____________________
6. Do you have any physical disabilities or limitations, such as past or existing injuries that we
should be aware of) Please be specific _______________________________________________
______________________________________________________________________________
7. Date of last Tetanus booster? ____________________________________________________
8. Are you currently on medication? ______ Medication and doses________________________
______________________________________________________________________________
8. Is there any other condition that we should be aware of that may endanger, alter of somehow
limit your ability to participate in any Sassafras’ Program? _______________________________
______________________________________________________________________________
9. Is your child in a special education program? _____________________ If yes, please describe:
______________________________________________________________________________
______________________________________________________________________________
10. Name of Health Insurance Carrier ______________________ Group plan # ______________
11. Physician ___________________________________ Physician’s Phone ________________
Provided parents or emergency contacts cannot be reached within reasonable time, I hereby
voluntarily consent to the rendering of care, including diagnostic procedures, surgical and medial
treatment, by authorized members of the hospital staff or their designees, as may in their
professional judgment be necessary. I hereby acknowledge that no guarantees have been made to
me as to the effect of such examinations or treatment on child’s/my condition. I acknowledge that
I am responsible for all charges in connection with care and treatment rendered during this period.
______________________________________________________________________________
Signature of parent/guardian/adult
Printed name
Date