2024 – Little Naturalists Session 9 Please double check all information is correct prior to submitting application. Please do not use autofill for this application. Your Name* First Last CHILDS's Name* First Last Child's Nickname (if applicable) First This will be the name that will be used for nametags and attendance if this section is completed.Child's Date of Birth* Month Day Year Child's Age at Time of Camp (must be 4,5, or 6 years old)* Cell Phone #*Your Email* Enter Email Confirm Email All confirmations will be sent to this email address, including any changes in the weeks schedule, or updates on the program. Please use an email that you regularly check and make sure that it is typed correctly. Additional Email (Parent/ Guardian) Enter Email Confirm Email All confirmations will be sent to this email address, including any changes in the weeks schedule, or updates on the program. Please use an email that you regularly check and make sure that it is typed correctly. Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shirt Size*Youth XSYouth SYouth MYouth LYouth XLSize Chart = Youth XS: 2/4, Youth S: 6/8, Youth M: 10/12, Youth L: 14/16, Youth XL 18/20Quogue Wildlife Refuge reserves the right to use photographs/ videos taken at camps, programs and events for use on our website, publications, and social media.Health and Emergency Contact InformationYou will be listed as the 1st Emergency Contact. ** PLEASE LIST TWO EMERGENCY CONTACTS IN ADDITION TO YOURSELF. If listed, these contacts will be approved for pick-up and must show a photo ID at camp pick-up.Emergency Contact Name #1* First Last Emergency Contact Phone #*Relationship to Child* Emergency Contact #2* First Last Emergency Contact Phone #*Relationship to Child* Approved Persons for pick-up (names must match the persons photo ID at pick-up) – Please list people who will be or will likely be picking up your child.*example: Babysitters, Family Friends, Grandparents. Must show a photo ID at the time of pick-up*** Please List Your Child’s Allergies & Medications Below****Please List any other Medical or Behavioral History (restrictions/limitations, special needs, dietary concerns, etc…):*If your child attends school with an aid, please inform Quogue Wildlife Refuge staff. At this time, we are not able to provide 1:1 supervision and therefore an aid must be provided. Please contact Refuge staff, as information on the aid must be provided before the start of your child’s camp week (as per Suffolk County Health Department). Please send or attach any treatment, care, and behavioral plans if applicable. Parental Consent – Emergency Statement (Please read and sign/initial your consent)* This form will be valid for 2024. I hereby grant permission for my child (named above) to attend the Quogue Wildlife Refuge Little Naturalist Program and participate in all activities listed. In the event of a medical or weather emergency and/or the inability to contact the designated guardian(s) in such an event, I agree that the Quogue Wildlife Refuge Staff may take such emergency measures, including transportation, as they deem appropriate and shall notify the parent and legal guardian as soon as possible. PaymentAre you a 2024 Member?* No Yes Member Registration Fee (Little Naturalist Week 9)* Price: Please note that you need a current Family level membership or higher to receive the discounted registration for Summer Camp. Family Memberships are only valid for the immediate family (i.e Parents and Children – not Grandchildren). To become a member visit https://quoguewildliferefuge.org/get-involved/become-a-member-today/ or call 631.653.4771. You can become a member at any time.Non Member Registration Fee (Little Naturalist Week 9)* Price: STOP. You MUST be a 2024 member of the Refuge to enroll during the priority registration period until 05/11/2024. Non-members are welcome to register after 05/11/2024 OR become a member today. To become a member visit https://quoguewildliferefuge.org/get-involved/become-a-member-today/ or call 631.653.4771. You can become a member at any time.Payment Type*Credit/Debit CardCheckEnter name on check below.* Send checks to PO Box 492, Quogue NY 11959 – *Check must be postmarked within one week of this form submission and received before camp begins to ensure your reservation.Refund Policy* By selecting this box, I am confirming that I have read, understand, and will comply with the following Refund Policy: A 50% refund will be granted if cancellations are received at least 30 days prior to the start of the camp session. There will be NO refund if the cancellation occurs within 30 days of the first day of the session, therefore please choose your sessions carefully and mark them in your calendar. Cancellation requests must be made by email to: Programs@QuogueWildlifeRefuge.org *(Strictly enforced!)* Switching camp weeks (if available) will be subject to an additional $50 processing fee per application. Payment Method*Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Total $0.00