FAMILY CLASS APPLICATION

All applications must be submitted by mail with full payment per course.     
Sorry, but no email applications can be accepted.   This application is for VA, MD and WV Earth Connection courses.
                        Please use the Earth Connection NC application for their courses.
Please fill out the following form, PRINT, SIGN and MAIL along with full tuition to:  

Earth Connection
P.O. Box 32
Somerville VA 22739
Please identify yourself: Please provide the following contact information:
Name of parent/s or guardian
Age
Sex Male Female
Name of child and age
Name of child and age
Name of child and age
Name of child and age
Name of child and age
Name of child and age
Name of child and age
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Emergency Contact Name and Phone Number:
Does anyone in the family have any special needs?   NO    YES 
Does anyone in the family have any allergies to foods, medications and/or insects; or any health concerns? If yes please explain:    NO    YES 
Please select the course(s) for which you are registering:   Enter the date of the course you would like to attend:
What are your goals for this (these) course(s)?
How did you hear about us?

WAIVER (all applicants must read and sign this waiver)
In all courses, events and excursions conducted by Earth Connection - it�s assistant instructors, helpers, and Tim MacWelch, individually - reasonable care is taken to prevent serious injuries and  minimize accidents. The student states that he or she is in good physical and mental health; and fully aware that survival, primitive technology, eating wild plants, and wilderness travel may be dangerous. The student by signing their name below hereby agrees to accept full responsibility for themselves and assume all risks, including those caused by acts of God, injury, death and/or loss to his or her person and/or property. The student hereby waives all present and future rights to make any claims resulting in any way from attending current or future courses, events or excursions conducted by Earth Connection, its assistant instructors, helpers, and Tim MacWelch, individually.  
Signature of Parent:                Date: 
(DO NOT TYPE - MUST BE WRITTEN SIGNATURE)
OPTIONAL - By initialing below, the student releases Earth Connection to use photographs taken during courses which may contain images of the students, for Earth Connection's advertising purposes.  
Parent's Initials:  (Do Not TYPE- Must be Written Initials)                                                                     

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