Thank you for your interest in Lake Thoreau Environmental Center’s Nights at Thoreau! Please complete this
registration form, email or mail it to the address listed at the end of the application or fax it to Mike Davis at
1) 266-5797. Onc
e we receive it, we will send you specific information about the program including directions to
Lake Thoreau.
The total cost for the program is $40 ($36 or $32 for Friends of Lake Thoreau members) and includes snacks and breakfast
the following morning. Participants can be dropped off between 6:00 P.M. and 6:30 P.M. on September 27
can be picked up between 8:00 A.M. and 8:30 A.M, September 28
. We look forward to seeing you out at Thoreau!
Participant Information
Participant Name: ________________________________________________ Female Male
Is this participant a member of the Friends of Lake Thoreau program? Yes, ID # ________ No
Price of the program: $40 *($36 or $32 for Friends of Lake Thoreau members)*
Method of Payment: Cash
Check Credit card. *If credit, please visit
Make check out to: USM Biology
If you are not a Friends of Lake Thoreau member or are a member but have recently changed your information, then please fill out
the remaining registration form listed below. If you are members and nothing has changed from your original membership form,
then you can stop here.
Participant Personal Information
Date of Birth: __________________ Presently enrolled at _______________________________________
School Grade in Fall 2019 3
Parent(s) or Guardian(s) Contact Information
Parent(s) or Guardian(s) Name: _____________________________________________________
Mailing Address_____________________________________________________________________________
Street City State Zip
Phone Number(s):
Father ______________ Mother ______________ Guardian ______________
In case of emergency, contact:
Father Mother Guardian
Email Address: _________________________________________________________________________
Yes, I would like to receive information about other events through the Biological Sciences Department at USM
To the Parents or Guardians of the Participant:
For your child to receive medical care in the event of illness or injury while participating in the USM event, we ask
that you bring a copy of all relevant insurance information for your child with you to the event. We will store it
securely until the end of the program, where we will then return the copy to you.
Is it permissible to provide medical treatment for your child if needed? Ye
s No
Please state any special medical conditions that may require staff attention:
Does your child take medication on a regular basis of which we need to be aware? Yes No
If yes, please explain:
Does your child have any known allergies? If yes, please explain: Yes No.
Is your child under the care of a psychologist/psychiatrist, or being treated for Yes No
any emotional or mental issues?
If yes, please explain:
Are there any restrictions of physical activity that may apply to your child? Yes No.
If yes, please explain:
Yes, I grant permission for my child to be photographed or videotaped during this event. This includes photos
that may be used for promotional or publicity purposes.
I certify that my child has permission to attend the Nights at Thoreau event at USM’s Lake Thoreau Environmental
Center. I release USM from any and every liability, claim, right of action of any kind or nature which my child or legal
representative may have for any and all bodily or personal injuries or property damages or any other damages resulting
there from which might occur during participation in this program and host institution(s), or representative(s) thereof,
and the management or owner(s) of any physical facility in which the program is conducted.
Parent or Legal Guardian’s Name (Print, please): _________________________________________________
Parent or Legal Guardian’s Signature: _________________________________________________________
Date: __________________________
Send to: For questions, please email Mike.Davis@us
m.edu or call at (601) 520-1038.
Mike Davis
Dept. of Biological Sciences
v. of Southern Mississippi
118 College Drive #5018
ttiesburg, MS 39406-0001
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