CELEBRATING OVER 125 YEARS!

donate

membership

YOu are here: » Medical Information and Release Form

Education Program Medical Information and Release Form

Are you coming to the Buttonwood Park Zoo for a Critter Camp-In or Twilight Tour? We can’t wait for you to join us on! Please complete the form below one week before your program is scheduled.

    What program are you attending?


    Parent/Guardian Name*


    First Child's Name*

    Second Child's Name


    Address

    Country


    Please select the date of your program.*

    Critter Camp-In T-shirt: Are you interested in purchasing a glow-in-the-dark Critter Camp-In t-shirt (“I Survived the Night at Buttonwood Park Zoo”) for $12? If so, please select the size(s) below and bring the appropriate amount of money in either cash or check (made out to the Buttonwood Park Zoological Society) to the night of your event.*


    General Release: In consideration for the services rendered to my above named child, I specifically release and hold harmless the Buttonwood Park Zoo, the Buttonwood Park Zoological Society, and the City of New Bedford, their agents, servants, volunteers, and employees from any and all liability, claims, damages, and causes of action I may now or hereafter have as parent of said minor(s). Further, I hereby give permission for my child to engage in any and all programs and activities of Buttonwood Park Zoo.*


    Emergency Authorization: In the event that I cannot be reached, I authorize the Overnight Program Coordinator and medical staff at St. Luke's Hospital to make decisions regarding the emergency care or treatment of my child.*


    Media Release: I hereby give permission for pictures and video to be taken of my child to be used for publication purposes. Children will not be identified in photos and video footage.


    Participants(s) Medical Information

    Medication*


    Is the participant currently taking prescription medication that will need to be taken during the event? If yes, please list:

    Allergies*


    Please list all allergies for participant(s).

    Additional Information*


    Please list any health or personal concerns that the Overnight Program Coordinator should be aware of in regards to the participant (please include any fears or phobias that may require special attention):


    Emergency Contact Information

    Please provide an additional emergency contact. If you will be participating in the event, please designate an emergency contact other than yourself.

    Name*

    Phone*

    Name*

    Phone*


    Fine Print

    Refund & Registration Polices: No refund will be given unless a program is cancelled by the Zoo. The Zoo reserves the right to cancel any class which does not meet the minimum enrollment criteria. Thank you for your cooperation. For further information, please call (508) 991-6178 x 67419. Inclement weather cancellations will be available at www.bpzoo.org.


    A Gift That Lasts All Year! 

    BPZOO Memberships make a perfect gift for the animal lover in your life.