Renewal Form Page

Student's Name *

First

Last

Student's Birthdate *

Student Prefers to Be Called *

Pronouns *

Student's Email *

Student's Phone Number *

Student's Address *

Line 1

Line 2

City

State

Zip Code

Country

Do you prefer hard copy or electronic newsletter? *

Hard Copy Electronic

Student's Favorite Bird *

Health History For Youth Attending Field Trips

Insurance Information

If you selected "No", please type N/A for the following questions.

Student's Medical Information

Emergency Medical Authorization Form
O.R.C. 3313.712

Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who will become ill or injured while under authority of Black Swamp Bird Observatory and all chapter partners when parents or guardians cannot be reached.

Part I: To Grant Consent:

I hereby give consent for the following medical care providers and local hospital to be contacted:

In the event that reasonable attempts to contact me have been unsuccessful, I hereby give Black Swamp Bird Observatory and all partnering chapter organizations’ representatives my consent for (1) the administration of any treatment deemed necessary by the above named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical options of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Part II: Refusal to Consent:

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Field Trip Permission

For and in consideration of the participation of the above-named child in the Ohio Young Birders Club (OYBC), a program of the Black Swamp Bird Observatory (BSBO), I/we, the parents of the above-named child hereby give permission for the participation of said child in any and all activities of the OYBC, which may include but are not limited to; hiking in tall grass (and possible poison ivy areas), along rocky trails or near water; being outdoors during all types of weather, using equipment such as binoculars and spotting scopes and catching live animals (bird banding).

Furthermore, we release, discharge and forever hold harmless OYBC, BSBO, and all chapter partners and their employees, officers, directors, trustees, volunteers and agents, including any person transporting said child to and from OYBC activities, and the organizers and sponsors of said activities, from and against any and all claims, damages, obligations, liabilities, loss, costs and/or expenses, arising out of any aspect of said child’s participation in OYBC and/or BSBO activities.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Photo Use Consent

From time to time throughout the year, an occasion may arise where we would like to publish a photo or video that includes your child, and your child’s name in print and/or in online publications of Black Swamp Bird Observatory, Ohio Young Birders Club, and/or all chapter partners. By signing this form you are giving us permission/denying us permission to publish your child’s photograph and name.

Student's Information

Health History For Youth Attending Field Trips

Insurance Information

Student's Medical Information

Emergency Medical Authorization FormO.R.C. 3313.712

Field Trip Permission

Photo Use Consent

Emergency Medical Authorization Form
O.R.C. 3313.712