Wild Adventure Program Health & Emergency Contact Form

Wild Adventure Health Form 2025

Please fill out the form below before the start date of the Wild Adventure Program your child is registered for. If you have any questions, you may contact Bob Clark at earthltdsummerprogram@gmail.com.

Child's Information
Please select which program your child is registered for.*
Name*
First Last
Age*
Date of Birth*
Month
Day
Year
Gender Identity*
Home Address*
Street Address Address Line 2 City State ZIP Code
Please list any special information or instructions regarding child (allergies, health issues, etc.)
Parent/Guardian & Emergency Contact Information
Parent/Guardian Name*
First Last
Is home addess same as child's?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Would you like to recieve email newsletters from EARTH Ltd and Southwick's Zoo?
- Yes
- No
Phone*
Insurance Provider*
Health Card Number*
Does your child require medication to be administered or supervised by Wild Adventure program staff?*
- Yes
- No
Photo Waiver
Do you release and approve the use of pictures taken of your child to be used in promotional material (brochures, etc) and/or for use on the Southwick's Zoo or EARTH Ltd. websites and social media? (Please note your answer will not affect registration)*
- Yes
- No
Acceptance of Risk and Permissions
If at any time medical treatment is necessary for my child, I give consent for treatment to be given. I understand that every effort will be made to contact the child’s parent or guardian prior to emergency treatment. Participants may withdraw from Wild Adventure Programs at any time. There will be no refunds after the first day of a program. I am fully aware of the potential risks of being involved in an outdoor summer program. I accept the risks of these hazards for my child voluntarily. I will indemnify and hold harmless Earth Ltd. or Southwick’s Zoo or its employees for any loss or injury that may result from my child’s voluntary participation in Wild Adventure programs, whether caused by negligence of the releases or otherwise.
Parent/Guardian Digital Signature*
Date*
MM slash DD slash YYYY

Wild Adventure Health Form 2025

Child's Information

Parent/Guardian & Emergency Contact Information

Photo Waiver

Acceptance of Risk and Permissions