Dinosaur discovery adventures
Participant Name *
Participant Name
Select Program *
Home Address
Home Address
Parent Cell Phone *
Parent Cell Phone
Participant Cell Phone
Participant Cell Phone
Particpant Date of Birth *
Particpant Date of Birth
Emergency Contacts
Emergency Contact 1 *
Emergency Contact 1
Emergency Contact 1 Phone *
Emergency Contact 1 Phone
Emergency Contact 2 *
Emergency Contact 2
Emergency Contact 2 Phone *
Emergency Contact 2 Phone
Participant Medical Information
Name on Participant's Insurance Policy *
Name on Participant's Insurance Policy
Authorization for Emergency Medical Care *
Primary Physician Phone
Primary Physician Phone
Media Release
Media Permisions
We take a lot of pictures and video of your family participating in our programs. We'd like your permission to use those photos in our marketing and to post videos online so other families can share the expereience. Please give us your permission to use photos and videos of your family by checking the box below
Liability Waiver and Assumption of Risk Agreement *
In consideration of my use of the premises of Paleo Park and my involvement with John Hankla and the Dinosaur Discovery Adventures field school in Paleontology, I for myself, my heirs, personal representative or assigns, do hereby release, waive, discharge, and covenant not to sue John Hankla, Kristen Zerbst Stauffer, Their trustees, directors, officers, employees, volunteers and agents from liability from any and all claims including negligence resulting in personal injury, accidents, or illnesses (including death) and property loss arising from use of premises. The Dinosaur Discovery Adventures curriculum carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I have read the previous paragraphs and I know and understand and appreciate these and other risks are inherent in the activity I am participating in. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. I also agree to indemnify and hold harmless John Hankla, Kristen Zerbst Stauffer, their trustees, directors, officers, employees, volunteers and agents from any and all claims, actions, suits, costs, expenses, damages and liabilities including attorney fees as a result of this use of premises. The undersigned further expressly agrees that the forgoing waiver and assumption of risk agreement is intended to be as broad and inclusive as is permitted by the law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect
Parent Name *
Parent Name
Today's Date *
Today's Date

Intake Form

We can’t wait to have you on board! Please fill out and submit the following form for enrollment.  Please Note: It is your responsibility to notify Robert Coleman and the Westhampton Beach Middle School PALEOS team if any of the following information changes.