Registration Form
for Fall 2009 Workshop for Grands

Please print out this form, complete it (using one form for a grandparent/grandkid team), and mail it with your payment to:

Astronomy Workshops
PMB144
1400 Main St NW Ste C
Los Lunas NM 87031

Make your check or money order for $200 payable to: UNM Biology Sevilleta Field Station

PLEASE PRINT NEATLY. THANK YOU!

Grandparent's Name: Address: City, State, Zip: Telephone (circle HOME or WORK): Cell phone: E-mail: We will never sell, rent, trade, or share your e-mail address.

Grandkid's Name: Grandkid's Age: Address: City, State, Zip: Name of Parent/Legal Guardian of Grandkid: Parent/Legal Guardian's Telephone (circle HOME or WORK):

Grandparent's Emergency Contact Name: Emergency Contact Phone Number: Grandkid's Emergency Contact Name: Emergency Contact Phone Number:

Optional - Medical Information You are not required to complete this section. However, if either of you become ill or injured and are unable to communicate, the instructors could provide this information to emergency personnel. Only the instructors would have access to this information. FOR GRANDPARENT Allergies: Blood Type: Medical Condition(s): Medications: Primary Care Physician's Name: Primary Care Physician's Phone Number: FOR GRANDKID Allergies: Blood Type: Medical Condition(s): Medications: Primary Care Physician's Name: Primary Care Physician's Phone Number:

Acknowledgment/Release for Grandparent I understand that Sevilleta National Wildlife Refuge is a natural environment with the potential for risks and hazards such as may be found in remote wilderness areas in New Mexico. I understand that STAR-HOPPERS, the University of New Mexico, and Sevilleta National Wildlife Refuge do not provide insurance coverage for any medical care I may need while participating in the Fall 2009 Weekend Workshop in Astronomy. Furthermore, I attest and verify that I am physically able to participate in the Fall 2009 Weekend Workshop in Astronomy, including but not limited to the two field trips, and I accept the inherent risks and hazards of my participation in this workshop, including but not limited to accidents or illness. I do hereby, for my heirs, executors and administrators, waive, release, and forever discharge any and all rights and claims for damages which I may have, or which hereafter accrue to me, against STAR-HOPPERS, the University of New Mexico, or the Sevilleta National Wildlife Refuge, in connection with my participation in the Fall 2009 Weekend Workshop in Astronomy. I have read this statement, I understand it, and my signature confirms its full acceptance. Signature of Grandparent: Print Name: Date:

Photo Release for Grandparent I hereby authorize STAR-HOPPERS Weekend Workshops in Astronomy to use candid photos of me, taken at the Fall 2009 Weekend Workshop in Astronomy while engaged in workshop activities, for the purposes of promoting and publicizing future workshops. I understand that said promotion may include but not be limited to use on brochures, flyers, display ads, and the STAR-HOPPERS website. I understand that I will not be identified by name on any promotional materials or media. I acknowledge that STAR-HOPPERS may also use said photos to support their grant applications and other requests for funding. I waive all rights, now and in the future, to monetary or other compensation for the use of the above-referenced photos for the above-stated purposes. Signature of Grandparent: Print Name: Date:

Acknowledgment/Release for Grandkid I am the parent or legal guardian of ________________________________________________________________, [print name of child attending workshop], a minor child. My child has my permission to attend the Fall 2009 Weekend Workshop in Astronomy with his/her grandparent. I understand that Sevilleta National Wildlife Refuge is a natural environment with the potential for risks and hazards such as may be found in remote wilderness areas in New Mexico. I understand that STAR-HOPPERS, the University of New Mexico, and Sevilleta National Wildlife Refuge do not provide insurance coverage for any medical care my child may need while participating in the Fall 2009 Weekend Workshop in Astronomy. Furthermore, I attest and verify that my child is physically able to participate in the Fall 2009 Weekend Workshop in Astronomy, including but not limited to the two field trips, and I accept the inherent risks and hazards of his/her participation in this workshop, including but not limited to accidents or illness. I do hereby, for my heirs, executors and administrators, waive, release, and forever discharge any and all rights and claims for damages which I or my child may have, or which hereafter accrue to me or my child, against STAR-HOPPERS, the University of New Mexico, or the Sevilleta National Wildlife Refuge, in connection with my child's participation in the Fall 2009 Weekend Workshop in Astronomy. I have read this statement, I understand it, and my signature confirms its full acceptance. Signature of Parent/Legal Guardian: Print Name: Date:

Photo Release for Grandkid I hereby authorize STAR-HOPPERS Weekend Workshops in Astronomy to use candid photos of my child, _______________________________________________________________________ [print name of child attending workshop], taken at the Fall 2009 Weekend Workshop in Astronomy while engaged in workshop activities, for the purposes of promoting and publicizing future workshops. I understand that said promotion may include but not be limited to use on brochures, flyers, display ads, and the STAR-HOPPERS website. I understand that my child will not be identified by name on any promotional materials or media. I acknowledge that STAR-HOPPERS may also use said photos to support their grant applications and other requests for funding. I waive all rights, now and in the future, to monetary or other compensation for the use of the above-referenced photos for the above-stated purposes. Signature of Parent or Legal Guardian: Print Name: Date: