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2. Organization Name*
4. Contact Name*
5. Preferred Contact Number*
7. Preferred Email Address*
8. Alternative Contact Number
10. Organization Street Address*
11. City, State*
12. Zip Code*
14. Program Selection*
    -- Select One --Reptile PresentationWhat's Wild?Oh Deer!Wild BabiesPollution SollutionSwamp SnackersHidden WorldOutreach - Reptile PresentationOutreach - Other

    Please dress appropriately for outdoor programs. Programs are conducted rain or shine. In the case of severe inclement weather we will substitute an outdoor program with an indoor program whenever possible. In the case of emergency weather your program may be cancelled and full refund will be issued if a reschedule is unavailable.
    
    Need to request a program modification? Please contact the park office at 706-312-7358 before submitting this form.

16. Number of Participants*

    1. 0 - 10
    2. 11 - 25
    3. 25+
17. Number of Chaperones*
19. Grade(s)/Age(s) of Participants*

    1. Pre-K (3-5yo)
    2. Kindergarten
    3. First Grade
    4. Second Grade
    5. Third Grade
    6. Fourth Grade

    1. Fifth Grade
    2. Middle School
    3. High School
    4. Adult Group (18+)
    5. Senior Group (55+)
    6. Scout Groups
21. Date of Visit: First Choice*
    Date of Visit: First Choice
22. Date of Visit: Second Choice*
    Date of Visit: Second Choice
24. Preferred Arrival Time*
    -- Select One --10:00am11:00am1:00pm2:00pm3:00pm
25. Will your group be enjoying lunch during your visit?*

    1. Yes - After Guided Program
    2. Yes - Before Guided Program
    3. No
27. Additional Information or Special Requests

    Please alert us to any accommodation requests for your group during your visit. Examples include but are not limited to: alternative arrival time requests, the use of large buses and/or multiple vehicles for transport, and any mobility or sensory considerations.

29. Cancellations, Refunds or Rescheduling

    Full refunds will be given up to two weeks prior to the date of your scheduled visit or emergency conditions force a cancellation. All efforts will be made to reschedule if desired but there is no guarantee as to the availability of dates. In the case of severe inclement weather we will substitute an outdoor program with an indoor program whenever possible. We reserve the right to modify, reschedule, or cancel programs due to employee emergency or illness.

31. Acknowledgements*

    Please check each statement for acknowledgement

    1. I have read, understand, and agree to the information and policies outlined in the "Private Program Information Guide"
    2. Submission of a request form does not guarantee the date(s) or program(s) requested. All requests are subject to final approval by Columbia County Parks, Recreation, and Events staff.
    3. Once a request is approved your program date and time will be held until payment is received. Payment must be received at least two weeks prior to the date and time of your requested visit. Your program will be confirmed when you receive an emailed receipt.
    4. I hereby assume all risks and hazards incidental to participation during this event and I do release and hold harmless Columbia County, its employees, and participants from all suits, claims, injuries, damages and demands for any and all forms of damages or injury to persons or property resulting from or in any way associated with my attendance at this event.
    5. The Parks, Recreation & Events Department may take and use photos of participants for publicity purposes. Photos of participants are used in the County's activity guide and other media publications. I hereby grant Columbia County Parks, Recreation & Events permission to use either the likeness, name, voice and words in any broadcast, telecast or print media account of this event or activity free of charge.
33. Signed*
    Signed

    Signed
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field