Delaware Nature Society

Program Application
Ashland Nature Center/Coverdale Farm: Fall, Winter, Spring

To apply, fill-in the form below and:

1) Print it out and send with payment (check or credit card info) to:
Delaware Nature Society / Ashland Nature Center - P.O. Box 700 - Hockessin, DE 19707

. . . or . . .

2) Fax with Credit Card Information to: 302-239-2473

Note: If you fax the registration, please call Ashland Nature Center to verify that the application was received. Contact: 302-239-2334, ext. 134

Full Names of Everyone in the Household Adult:
Work Phone #:
Cell Phone #:
Adult:
Work Phone#:
Cell Phone #:
Child:
Child's Birth Date:
Child:
Child's Birth Date:

Person Filling Out This Form: Home Phone:
E-Mail:
Address:

City:
State: Zip:

Program Registration: Registrant:
Child's birthdate
Program ID Program Date
Program Name

Registrant:
Child's birthdate
Program ID Program Date
Program Name

Confidential Medical & Emergency Information

Note: Please be sure to fill in the following information about medications, allergies, physical disabilities or restrictions that the instructors should know:

Child's physician: Name
Phone #:
Child's insurance: Name
Child's Insurance policy #

Yes No: In case of an emergency, I give permission to have. . .
(Child/Children)
. . . receive first aid and be transported to the nearest hospital by professional, emergency personnel. I understand I will be financially responsible for the cost of such treatment.

______________________________________ (parent/guardian)

_____________________ (date signed)

Membership - Delaware Nature Society

You will receive a membership card and tax receipt by mail. Please be assured that the Delaware Nature Society does not release, sell, or in any way share our donors' addresses with any third party. Click for Membership Benefits information.

Check One:

College Student $30	Senior Citizen $30	Individual (Adult)$40
Household $55	Household Plus $85	Sustaining $125

Enclosed is:
$ for programs + $ for membership = $ Total

Payment Method (check one):

Check, payable to Delaware Nature Society

Credit Card: VISA MasterCard

Credit card # ___________________________ Expiration date: (mm/yy)______/______

Authorized Signature___________________________________________________