What program are you attending?

—Please choose an option—Critter Camo-In (overnight)Twilight Tour (evening only)

Parent/Guardian Name*

First Child's Name*

Second Child's Name

Address

Country

-----AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCanadaCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & S. Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

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.*

Youth MYouth MYouth LYouth LYouth XLYouth XLAdult SAdult SAdult MAdult MAdult LAdult LNo t-shirt

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.*

—Please choose an option—Please check here if you agree to the above general release.Please check here if you do not agree to the general release statement above. Please note: this will prohibit participation in event.

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.*

—Please choose an option—Please check here if you agree to the emergency authorization statement above.Please check here if you do not agree to the emergency authorization statement above. Please note: this will prohibit

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.

—Please choose an option—Please check if your agree to the media statement above.Please check if you do not agree to the media statement above.

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.

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.