Wild about Science Afterschool Program Step 1 of 3 33% Participant InformationParticipant Name* First Last Current Grade Level:*Select one:Kindergarten1st Grade2nd GradeMedical InformationWe ask you to complete this information so that we may provide the safest course possible. Your information allows us to address any needs, take proper precautions, and provide a positive experience for all students. As you answer the questions, please keep in mind the demanding nature of this course. Known Allergies (please check all that apply):*Even if an allergy is well-controlled by a student and may not seem relevant to this course, it is very important that we are aware of all known allergies, regardless of their nature, so we can help prevent a reaction from occuring. Food Allergy Medication Allergy Insect Bites/Stings Plants Other None Known Allergies History*Please provide additional information about any known allergies. Please have your student bring an Epi-Pen if s/he has any known allergies that could cause anaphylactic shock.Are there any dietary restrictions? (please select one):* Yes No Dietary Restriction Information*Please explain.Additional InformationPlease add anything not previously mentioned that may have an effect on the student's success both physically, academically, or emotionally. Please add anything you would just like us to be aware of so we can provide a successful experience.Parent/Guardian InformationParent or Guardian Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary Phone*Alternate Phone #1Alternate Phone #2Email* Waivers and ReleasesPermission to Transport: In certain instances, students will be transported to locations other than the Northern Susitna Institute campus via foot, a vehicle, or watercraft (motorized and/or non-motorized) in order to participate in certain activities. Parents and guardians will be notified prior to each instance. Please indicate whether or not you grant permission to transport your child.*I grant permission to NSI to transport my child when appropriate for activities associated with the NSI program for which my child is enrolled.I decline to grant permission to NSI to transport my child.Photo Release: I understand that photos and/or videos may be taken of my child during the course of their participation in the NSI program. Please indicate whether or not you grant permission to use photos and/or videos of your child for promotional purposes, such as social media posts and/or print materials.*I grant permission to NSI to use photos and/or videos of my child for promotional purposes, such as social media posts and/or print materials.I decline to grant permission to NSI to use photos and/or videos of my child for promotional purposes, such as social media posts and/or print materials.Medical Release: By signing below, I give full permission to the instructors to have my child taken to a doctor, clinic or hospital as they deem necessary. My child, as listed, will be in the instructors' care during the dates of the course(s) listed, and the instructors have permission to have my child treated if medically necessary. I understand that medical insurance coverage and immediate payment are my responsibility. I understand that I am fully responsible for all expenses related to my child's medical treatment during or as a result of my child's participation in this course, including, but not limited to, treatment, transportation, food, lodging, accompanying instructor's expenses (including expenses for an instructor to return to the field), etc. Depending on the circumstances, a family member or other designated person may be required to pick my child up.* I testify that the information provided in this document is complete and accurate. I understand that I must inform Northern Susitna Institute if any information listed above changes between now and completion of the course. Release of Liability: In consideration of the services of Northern Susitna Institute (NSI), I, the above-listed student, and my parent(s)/legal guardian(s), agree and acknowledge as follows: Although Northern Susitna Institute has taken reasonable steps to provide me with appropriate equipment and skilled staff for the course for which I have enrolled in, I acknowledge that the activities of the program have risks, including certain risks which cannot be eliminated without destroying the unique character of the activities. The same elements that contribute to the unique character of these activities can cause loss or damage to my equipment, accidental injury, illness, or in extreme cases, permanents trauma, disability, or death. I understand that NSI does not want to frighten me or reduce my enthusiasm, but considers it important for me to know in advance what to expect and to be informed of the activities’ inherent risks. The following describes some, but not all, of those risks. • Participants will be out of doors, where they are subject to numerous risks, environmental and otherwise. • Equipment may fail or malfunction, despite reasonable maintenance and use. • Environmental risks and hazards include rapidly moving, deep or cold water; dangerous plants and animals, including large animals; falling and rolling rock; lightning, floods, and unpredictable forces of nature, including weather which may change to extreme conditions without notice. Possible injuries and illnesses include, but are not limited to, sunburn, hypothermia, frostbite, dehydration and other mild or serious conditions. • Decisions are made by the instructors & students usually in a wilderness setting, based on a variety of perceptions & evaluations which, by their nature, are imprecise & subject to reasonable errors in judgment. Misjudgments may pertain to, among other things, a student’s capabilities, environment, terrain, weather conditions, natural hazards, & medical conditions. I acknowledge that the staff of NSI has been available to more fully explain to me the nature and physical demands of these activities and the inherent risks, hazards, and dangers associated with these activities. I understand that the description above of the risks is not complete and that other unknown or unanticipated risks may occur. I expressly acknowledge and assume the inherent risks identified herein and those inherent risks not specifically identified. Therefore I assume and accept full responsibility for myself and for injury, death, and loss of personal property and expenses suffered by me as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence or otherwise wrongful conduct in participating in these activities. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of and with knowledge of the inherent risks. I understand that all final decisions will be made by the NSI instructors with the safety and well being of all students and instructors being first and foremost. I have instructed my child to obey the instructors and the rules and expectations they set forth. I understand that if the rules set forth are not followed, my son/daughter may be sent home at any point during the field course at my expense. Any dispute between NSI and me and/or my parent(s)/legal guardian(s) shall be governed by the substantive laws (not including laws which might apply the laws of another jurisdiction) of the state of Alaska, and any mediation or suit shall occur or be filed only in the State of Alaska. If I have any legal dispute with NSI which cannot be settled through discussions between the parties, I will attempt to settle the dispute through mediation before a mutually acceptable mediator whose name appears on the registry of names recognized by Alaska courts as qualified persons for mediation assignments. I also agree to pay all costs and attorneys’ fees incurred by NSI in defending a claim or suit if the claim or suit is withdrawn or to the extent a court or arbitration determines that NSI is not responsible for the injury or loss. If any part of this agreement is found by a court or other appropriate authority to be invalid, the remainder of the agreement nevertheless will be in full force and effect. This agreement is entered into voluntarily, after careful consideration and is binding upon the persons signing below, their heirs, executors, administrators, wards, minor children and other family members. THE STUDENT AND PARENT/LEGAL GUARDIAN HAVE READ THIS PAGE AND THE PREVIOUS PAGE AND FULLY UNDERSTAND AND AGREE TO THE ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS, ABOVE.* I have read the Release of Liability and Waiver Agreement, fully understand its terms and sign it freely and voluntarily. Cancellation Policy: Registration is not guaranteed until full payment is received. Cancellations that occur 30 days in advance of the program start date will be refunded the course fee, less a processing fee of $25 per space. For cancellations within 30 days of the program start date, the entire fee will be retained unless we can fill your space. If we cancel a program, your entire fee will be refunded.* I have read the Cancellation Policy, fully understand its terms, and sign it freely and voluntarily. Participant Name* First Last Parent or Guardian Name* First Last Parent or Guardian Signature*The online signature of the parent or guardian of the participant is legally recognized in the State of Alaska. Payment and Final StepsRegistration Fee*(enter "1" in quantity field) Price: $30.00 Quantity: I would like to add a donation to the scholarship fund in the following amount: Registration Fee Total $0.00 Payment Type*PaypalCash or CheckYour registration is not guaranteed until full payment is received. After clicking the "Register" button, your browser will automatically direct to PayPal. Please be patient while the next page loads. Do not click the back button or click the register button more than once.Your registration is not guaranteed until full payment is received. To arrange payment for your registration or inquire about scholarships, contact us by calling (907) 733-7111, mail a check to PO Box 46, Talkeetna AK 99676, or stop at the NSI office.