2017 Renewal Form
SPAT Suffolk Project in Aquaculture Training Cornell Cooperative Extension Marine Program 3690 Cedar Beach Road, Southold, NY 11971 (631) 852-8660
(631) 852-8662
2017 Renewal Form Yes, I would like to renew my participation in SPAT (Suffolk Project in Aquaculture Training) and continue to learn about aquaculture, tend a shellfish garden and help the community effort to restore shellfish to our waters and foster environmental stewardship.
Name______________________________________________________________________ Address____________________________________________________________________ ___________________________________________________________________________ City_____________________________________________State________Zip____________ Phone___________________________E-mail______________________________________ *Please indicate your email above. This is very important for keeping informed of events. *Please initial here_____________ to agree to our SPAT program hours. SPAT hours here at the Marine Center are only Monday, Wednesday, Friday from 8:30 am – Noon ,during which time you may tend to your oysters with other members. The marine center is closed on the weekends and there is no SPAT. Members may only tend to their oyster garden during the specific hours mentioned – there are no exceptions.
Participation fee of: _______
$150 Master Shellfish Gardener (at the Marine Center)
_______
$250 Ambassador Shellfish Gardener (at your dock in DEC certified waters)
_______
$155 Ambassador Renewal
_______
$500 or more $_______ Corporate Sponsor/Generous Supporter
_______
$100 Sustaining Member (no shellfish seed included) **Please make checks payable to Cornell Cooperative Extension, (SPAT in memo) _______ Check #
_______ MasterCard
_______ Visa
Card Number______________________________________________Expiration Date__________________ Signature________________________________________________________________________________ Cornell Cooperative Extension is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities. Cornell Cooperative Extension is funded in part by Suffolk County through the office of the County Executive and the County Legislature. Please contact Kim Tetrault at the Cornell Cooperative Extension of Suffolk County office (631) 852‐8660 if you have any special needs.
CCE F.O.R.M.CODE 1501 ATTACHMENT SECTION ACKNOWLEDGMENT OF RISK – ADULT SEPTEMBER 2008
ACKNOWLEDGMENT OF RISK, WAIVER & RELEASE ‐ ADULT (THIS FORM MUST BE COMPLETED BY ALL PARTICIPANTS 18 YEARS & OLDER) I, _________________________________________ the undersigned hereby apply to participate in the program described below to be conducted in cooperation with Cornell Cooperative Extension Association of Suffolk County and acknowledge as follows: I fully understand and acknowledge that there are inherent risks and dangers in my participation SPAT in the activities at ___________________ and my participation in said activities and use of any equipment or materials related to such activities may result in my injury, illness or death and/or damage to or loss of my personal property. I understand other participants, accidents, forces of nature or other causes may cause these risks and dangers and I hereby fully acknowledge and accept these risks and dangers. I am in good health and I am at or above the minimum age of 18 required to participate in this activity and I am able to participate in any strenuous physical activity associated therewith. I herewith release, forever discharge and waive any right of recovery from or subrogation against Cornell Cooperative Extension, its officers, directors, employees and volunteers from any and all liability whatsoever for any illness or injury, including death or damage to or loss of my personal property that I may sustain while I am participating in this program. This shall be binding on my heirs, successors, assigns, administrators and executors. Any claims or disputes arising out of my participation in the activity shall first be submitted to arbitration and/or be venued in the Supreme Court of the State of New York of the Suffolk County, the choice of which shall be at the sole discretion of CCE. I HAVE READ THE ABOVE OR I ACKNOWLEDGE, IF VERIFIED BELOW, THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY REQUEST AND BY SIGNING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN THE INDICATED ACTIVITY AND I UNDERSTAND AND ACCEPT ALL THE RISKS INVOLVED. 2017 DATE(S) OF PROGRAM: ______________________________________ SPAT Program DESCRIPTION OF PROGRAM: ________________________________________________________ PARTICIPANT’S FULL NAME (print) ____________________________________________ DATE OF BIRTH: ___________________ ADDRESS: ___________________________________________________________________ SIGNATURE: _________________________________________ DATE: __________________ WITNESS: ___________________________SIGNATURE: __________________________________ (Witness must be CCE employee or person in charge of the group) PRINT NAME: _______________________________________ DATE: ____________________ This form must be kept in CCE Association files for seven (7) years from date of event.
(631) 852-8662
2017 Renewal Form Yes, I would like to renew my participation in SPAT (Suffolk Project in Aquaculture Training) and continue to learn about aquaculture, tend a shellfish garden and help the community effort to restore shellfish to our waters and foster environmental stewardship.
Name______________________________________________________________________ Address____________________________________________________________________ ___________________________________________________________________________ City_____________________________________________State________Zip____________ Phone___________________________E-mail______________________________________ *Please indicate your email above. This is very important for keeping informed of events. *Please initial here_____________ to agree to our SPAT program hours. SPAT hours here at the Marine Center are only Monday, Wednesday, Friday from 8:30 am – Noon ,during which time you may tend to your oysters with other members. The marine center is closed on the weekends and there is no SPAT. Members may only tend to their oyster garden during the specific hours mentioned – there are no exceptions.
Participation fee of: _______
$150 Master Shellfish Gardener (at the Marine Center)
_______
$250 Ambassador Shellfish Gardener (at your dock in DEC certified waters)
_______
$155 Ambassador Renewal
_______
$500 or more $_______ Corporate Sponsor/Generous Supporter
_______
$100 Sustaining Member (no shellfish seed included) **Please make checks payable to Cornell Cooperative Extension, (SPAT in memo) _______ Check #
_______ MasterCard
_______ Visa
Card Number______________________________________________Expiration Date__________________ Signature________________________________________________________________________________ Cornell Cooperative Extension is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities. Cornell Cooperative Extension is funded in part by Suffolk County through the office of the County Executive and the County Legislature. Please contact Kim Tetrault at the Cornell Cooperative Extension of Suffolk County office (631) 852‐8660 if you have any special needs.
CCE F.O.R.M.CODE 1501 ATTACHMENT SECTION ACKNOWLEDGMENT OF RISK – ADULT SEPTEMBER 2008
ACKNOWLEDGMENT OF RISK, WAIVER & RELEASE ‐ ADULT (THIS FORM MUST BE COMPLETED BY ALL PARTICIPANTS 18 YEARS & OLDER) I, _________________________________________ the undersigned hereby apply to participate in the program described below to be conducted in cooperation with Cornell Cooperative Extension Association of Suffolk County and acknowledge as follows: I fully understand and acknowledge that there are inherent risks and dangers in my participation SPAT in the activities at ___________________ and my participation in said activities and use of any equipment or materials related to such activities may result in my injury, illness or death and/or damage to or loss of my personal property. I understand other participants, accidents, forces of nature or other causes may cause these risks and dangers and I hereby fully acknowledge and accept these risks and dangers. I am in good health and I am at or above the minimum age of 18 required to participate in this activity and I am able to participate in any strenuous physical activity associated therewith. I herewith release, forever discharge and waive any right of recovery from or subrogation against Cornell Cooperative Extension, its officers, directors, employees and volunteers from any and all liability whatsoever for any illness or injury, including death or damage to or loss of my personal property that I may sustain while I am participating in this program. This shall be binding on my heirs, successors, assigns, administrators and executors. Any claims or disputes arising out of my participation in the activity shall first be submitted to arbitration and/or be venued in the Supreme Court of the State of New York of the Suffolk County, the choice of which shall be at the sole discretion of CCE. I HAVE READ THE ABOVE OR I ACKNOWLEDGE, IF VERIFIED BELOW, THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY REQUEST AND BY SIGNING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN THE INDICATED ACTIVITY AND I UNDERSTAND AND ACCEPT ALL THE RISKS INVOLVED. 2017 DATE(S) OF PROGRAM: ______________________________________ SPAT Program DESCRIPTION OF PROGRAM: ________________________________________________________ PARTICIPANT’S FULL NAME (print) ____________________________________________ DATE OF BIRTH: ___________________ ADDRESS: ___________________________________________________________________ SIGNATURE: _________________________________________ DATE: __________________ WITNESS: ___________________________SIGNATURE: __________________________________ (Witness must be CCE employee or person in charge of the group) PRINT NAME: _______________________________________ DATE: ____________________ This form must be kept in CCE Association files for seven (7) years from date of event.
