Eco-Buddies Registration Form

Please print out this form and mail it to the address below. Please print clearly.

 

Parent/Guardian Name_______________________________________________

Address__________________________________________________________

City___________________________ State__________ Zip_________________

Home Phone______________________ Ask for__________________________

Work Phone_______________________ Ask for_________________________

Check One:  _____WEC Member       _____Non-member

 

Participant Name___________________________________________________

Age____________ Birthday____________________       ___Male    ___Female

Special Allergies__________________________________________________

Date	Session Name	Fee

Make check payable to Welty Environmental Center or WEC.     Total Amount:___________

_____Photographs of my child may be taken and used for promotional purposes.

The undersigned hereby releases the Welty Environmental Center and its employees, heirs, and assigns, from all liability as the result of any injury or damage that I/My Child/Ward may suffer as the result of participation in any program sponsored by the Welty Environmental Center.

Signature of Parent/Guardian__________________________________ Date___________

Mail this form to: Welty Environmental Center, 8606 County Road H, Beloit, WI 53511

Questions? Call WEC at (608) 361-1377.