Registration

Child Name *

First Name

Last Name

Preferred Name (if different)

First Name

Last Name

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Home Address (if different from the child)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Doctor *

First Name

Last Name

Doctor's Phone Number *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Policies, Permissions, and Waivers *

Acknowledgement of Risk. I, in my legal capacity as the parent/guardian of the minor named below, do hereby acknowledge, and agree that participation in youth program activities conducted or sponsored by Citizen Farmers., and its subsidiaries and affiliates, and its past or present officers, directors, managers, employees, supervisors, agents, or representatives and assigns (collectively known as the Citizen Farmers) comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with youth program and childcare activities (collectively, “Program”) participation, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with Workshops participation and that said list in no way limits the operation of this Agreement. Coronavirus / COVID-19 Warning & Disclaimer. Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating Citizen Farmers in program activities or accessing Citizen Farmers Academy could increase the risk of contracting COVID-19. Citizen Farmers in no way warrants that COVID-19 infection will not occur through participation in Citizen Farmers activities or accessing Citizen Farmers Academy. Consent to Medical Treatment. By signing this form I hereby give permission to Citizen Farmers staff to administer over-the-counter medications and physician-ordered medication to my child named above in cases deemed necessary, and in the event I cannot be reached in an emergency, I hereby give permission to Citizen Farmers to hospitalize, or secure proper treatment for, my child. I hereby FOREVER release, discharge, indemnify, hold harmless, defend, exonerate, and covenant not to sue Citizen Farmers from any and all liability or claim whatsoever which arises or may hereafter arise, directly or indirectly, on account of any first aid, treatment, or medical service rendered in connection with the program activities participated in by my minor child with the Citizen Farmers, and I assume all risk associated therewith. I also understand that Heck.house does not and shall not assume any responsibility for or obligation to provide financial assistance or other assistance to me or to my minor child (if applicable), including, but not limited to, medical, health, or disability insurance in the event of injury, illness, or other claim or loss. Medication. Citizen Farmers Academy does not normally administer any medication and will do so only when directed in writing by the child’s parent or guardian. However, in the event of an emergency in which the parent cannot be contacted, Emergency Medical Staff and Citizen Farmers may take appropriate action in the best interest of the child. Accident Insurance. Participants are responsible for their own accident insurance when using Citizen Farmers and when participating in Citizen Farmers programs off-site. Blood Borne Pathogen Exposure. I understand that, while my child is in the care of Citizen Farmers, if a child is exposed to a body fluid on broken skin or mucous membranes (e.g. splashing in mouth or eye), from another child, Citizen Farmers will contact the parents of both children. They will explain what has occurred, and then provide the name of the attending physician of the source child to the parents of the exposed child. If a staff member has a blood or body fluid exposure from a child, Citizen Farmers Academy will provide the name and telephone number of the child’s attending physician to the staff member. I have read and agree with the statement and specifically authorize Citizen Farmers to release the name and telephone number of my child’s physician, and a description of the event to the parent or guardian of any child who is exposed to blood or body fluid or any staff member who experiences such an exposure from my child. Pickup Policy.Inclement weather.Please refer to local media sources or, if available, www.citizenfarmers.org/academy for program closings related to inclement weather. Lost Items. I understand that Citizen Farmers Academy is not responsible for any personal items lost or stolen at our programs. Photography. I permit Citizen Farmers to use images of my child as an Academy participant in internal and external promotional material. This includes any printed material, broadcast and print advertising, promotional videos and Citizen Farmers website which are produced or published by citizenfarmers.org. I also permit Citizen Farmers and/or the media to use images of my child in broadcast and print media news coverage of the Citizen Farmers. I understand that my child’s name is not published.

I consent to the above policies, permissions, and waivers

I do not consent and withdrawal my registration

Consent *

By signing below, I acknowledge that I have read the above information, and that I understand the policies and guidelines of the program and I agree to abide by them. Should I have any questions or concerns, I will contact the Program Director (Daron Joffe). I understand that the staff makes every effort to provide a quality program, but additionally it is important that participants and parents follow all rules, guidelines and procedures in order for the program to be a successful experience for all.

First Name

Last Name