Outdoor Education Program Registration

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Outdoor Education Program Registration

Please completely fill out this form.

If the form will not work for you, please call Amy Wilms at 765-827-5109. Amy will be happy to process your registration over the phone.

After submitting the form, you will automatically be directed to the next step to pay or request a scholarship.

This second step is very important.

Please ensure you complete both steps.

Cost is: $75 per child unless you are an intern or are awarded a scholarship.

Scholarships

Scholarships will be given to participants if a need exists. If your family needs assistance with paying the fee, please select the scholarship RSVP area and enter the number of children in your family requesting attendance. You’ll be asked how much you can pay based on your need. A short explanation of your need will be asked. Once approved (a few days later), you’ll receive an email or phone call asking for payment through PayPal (if applicable). Other payment options may also be available.

Final Registration

Parents/Guardians will receive a payment or event confirmation once everything is approved.

Questions?

Contact Pamela Herrmann
Email: [email protected]
Phone: 765-203-9092

Allow at least 30 minutes to fill out your full application.

 

 

Participant Information

First Name
First Name
Field is required!
Field is required!
Last Name
Last Name
Field is required!
Field is required!
School Attended
  • - select a option -
  • Grandview
  • Frazee
  • Everton
  • Eastview
  • St Gabriels
  • Maplewood
  • Fayette Central
  • Other
  • Connersville Middle School
  • Connersville High Shool
  • Community Christian
- select a option -
Field is required!
Field is required!
Grade Finished
  • - select a grade -
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
- select a grade -
Field is required!
Field is required!
Date of Birth
Field is required!
Field is required!
Age
  • - select a option -
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
- select a option -
Field is required!
Field is required!
Will a Friend be Registered?
Friend's Full Name
Field is required!
Field is required!
T-shirt Size
  • - select a option -
  • Youth Small
  • Youth Medium
  • Youth Large
  • Adult S
  • Adult M
  • Adult L
  • Adult XL
  • Adult 2XL
- select a option -
Field is required!
Field is required!
Address
Your Address
Field is required!
Field is required!
City
City
Field is required!
Field is required!
Site Where Participant Will be Dropped off and Picked Up
Choose one
Field is required!
Field is required!
Person Responsible for Drop off
Drop off contact full name
Field is required!
Field is required!
Drop off contact cell phone number
Drop off contact phone number
Field is required!
Field is required!
Person Responsible for Pick up
Pick up contact full name
Field is required!
Field is required!
Pick up contact cell phone number
Pick up contact phone number
Field is required!
Field is required!
Participant Lives with:
Participant Lives with:
Field is required!
Field is required!

Parent/Guardian Information

Parent/Guardian #1 - Primary Contact

Primary Contact Name:
Primary Contact Name:
Field is required!
Field is required!
Primary Contact Relationship:
Primary Contact Relationship:
Field is required!
Field is required!
Primary Contact Address
Primary Contact Address
Field is required!
Field is required!
Primary Contact City
Primary Contact City
Field is required!
Field is required!
Primary Contact Email address
Primary Contact Email address
Field is required!
Field is required!
Primary Contact Phone:
Primary Contact Phone:
Field is required!
Field is required!
Can we send texts to this number?
Field is required!
Field is required!

Volunteer to help

A background check will need to be on file with the Fayette County School System.
I'm interested in volunteering to help with the program
Field is required!
Field is required!
I have a background check on file with the Fayette County Schools
Field is required!
Field is required!
Background Check

Click on the button below to download and print the background check paperwork. Please take the printed and signed copy to the FCSC Administration Office prior to May 3, 2019.



Paperwork Link

Field is required!
Field is required!

Parent/Guardian #2

Parent/Guardian 2 Contact Name
Parent/Guardian 2 Contact Name
Field is required!
Field is required!
Parent/Guardian 2 Contact Relationship
Parent/Guardian 2 Contact Relationship
Field is required!
Field is required!
Contact 2 Address
Contact 2 Address
Field is required!
Field is required!
Contact 2 City
Contact 2 City
Field is required!
Field is required!
Contact 2 Email address
Contact 2 Email address
Field is required!
Field is required!
Contact 2 Cell Phone Number
Contact 2 Cell Phone
Field is required!
Field is required!
Can we send texts to this number?
Field is required!
Field is required!

Volunteer to help (Contact 2)

A background check will need to be on file with the Fayette County School System.
Second contact is interested in volunteering to help with the program
Field is required!
Field is required!
Second contact has a background check on file with the Fayette County Schools
Field is required!
Field is required!
Background Check

Click on the button below to download and print the background check paperwork. Please take the printed and signed copy to the FCSC Administration Office prior to May 3, 2019.


Paperwork Link

Field is required!
Field is required!
Alternate Emergency Contact
If Parent/Guardian 1&2 do not respond
Please list one additional person we can contact in case of emergency.
Field is required!
Field is required!
Alternate Emergency Contact Name
Alternate Emergency Contact Name
Field is required!
Field is required!
Alternate Emergency Contact Relationship
Alternate Emergency Contact Relationship
Field is required!
Field is required!
Alternate Emergency Email address
Alternate Emergency Email address
Field is required!
Field is required!
Alternate Emergency Contact Cell Phone
Alternate Emergency Contact Cell Phone
Field is required!
Field is required!
Can we send texts to this number?
Field is required!
Field is required!

Health Information

Family Physician
Family Physician:
Field is required!
Field is required!
Insurance Provider
Insurance Provider Name
Field is required!
Field is required!
Policy Holder Name
Policy Holder Name
Field is required!
Field is required!
Physician Phone
Physician Phone
Field is required!
Field is required!
Group Number
Group Number
Field is required!
Field is required!
Policy Number
Policy Number
Field is required!
Field is required!

Allergies

Please check all allergies that apply and list any known allergens.
Does the participant have allergies?
Field is required!
Field is required!
Allergy One
List Allergy
Allergy
Field is required!
Field is required!
Allergy One Reaction
List any reactions
Allergy 1 reactions
Field is required!
Field is required!
Allergy Two
List Allergy
Allergy 2
Field is required!
Field is required!
Allergy 2 reaction
Allergy 2 reaction
Allergy 2 reactions
Field is required!
Field is required!
Allergy Three
List Allergy
Allergy 3
Field is required!
Field is required!
Allergy 3 Reaction
List any reactions
Allergy 3 reactions
Field is required!
Field is required!
Allergy Four
List Allergy
Alllergy 4
Field is required!
Field is required!
Allergy 4 reactions
List reactions
Allergy 4 reactions
Field is required!
Field is required!

Special Needs

Check yes if the participant has special needs such as physical or behavioral issues.
Does the participant have special needs?
Field is required!
Field is required!
Special Need One
List the need.
Special need name
Field is required!
Field is required!
Please Explain
Explain the special need.
Field is required!
Field is required!
Special Need Two
List the need.
Special need name
Field is required!
Field is required!
Please Explain
Explain the special need.
Field is required!
Field is required!
Special Need Three
List the need.
Special need name
Field is required!
Field is required!
Please Explain
Explain the special need.
Field is required!
Field is required!

Medications

List any medications the participant is currently taking.
Is the participant taking medications?
Please answer yes or no
Field is required!
Field is required!
Medication
Name of medication
Field is required!
Field is required!
Provide instructions
Provide instructions if the participant will need to take a medication while under our care.
Field is required!
Field is required!
Medication
Name of medication
Field is required!
Field is required!
Provide instructions
Provide instructions if the participant will need to take a medication while under our care.
Field is required!
Field is required!
Medication
Name of medication
Field is required!
Field is required!
Provide instructions
Provide instructions if the participant will need to take a medication while under our care.
Field is required!
Field is required!

Waivers

Consent for Photographs
We have your consent for Outdoor Education Experience (OEE) at MGBS to use any photograph, picture or likeness of your child for promotional purposes
Field is required!
Field is required!
Consent for Medical Treatment
You give OEE staff your permission to seek medical treatment for your child while attending MGBS. This also authorizes MGBS OEE staff to administer First Aid or transport your child to a medical facility if the need arises.
Field is required!
Field is required!
Consent for Medication Administration
If a MGBS OEE staff member is to administer any prescription drug(s) to your child while attending camp, the prescription will be in the original bottle with the name, dosage, and frequency of administration and note with the time of last dose.
Field is required!
Field is required!
Medical History is Complete and Accurate:
The participant's health history is complete and accurate, and may engage in all activities.
Field is required!
Field is required!
I release Indiana Audubon Society from all liability, claims, demands, causes of actions, and possible causes of action:
I release Indiana Audubon Society from all liability, claims, demands, causes of actions, and possible causes of action: whatsoever arising out of or related to any loss, damage or injury that may be sustained by the participant while attending MGBS.
Field is required!
Field is required!

Activity Challenge

Parents have the opportunity to participate in an incentive program encouraging movement in conjunction with Outdoor Education. Please indicate if you would like to move more and win prizes.
I would like to participate in the activity challenge
Field is required!
Field is required!

Community Garden Participation

I would like to participate in the community garden
Save 50% off!
Field is required!
Field is required!
Community Garden Voucher
Click on the image to download or print.
Field is required!
Field is required!
garden voucher
Submit

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