Registration Form Jr. Homesteaders(8-13)Wednesdays 9-1pm Name First Name Last Name Phone (###) ### #### Email * Name of Child/Children attending * Age of child/children * Tell us briefly about your child and why you think LFNS might be a good fit. * Emergency Contact Name * First Name Last Name Emergency Contact Number * (###) ### #### Who else is authorized to pick up your child? * We will not allow your child to go home with any who is not authorized. A verbal authorization works too. (Example - Text, call, email and let me know name of person who is picking up.) Does your child have any allergies? If so, what are they? * Does your child have any health concerns/conditions we need to be aware of? Please also let us know if your child needs any specific accommodations. * Do you consent to have your photos of your child taken? * Photos are ok Photos without face No photos at all, please. I have read the LFNS Parent Handbook and am aware of the cost I owe and the schedule as outlined and understand my responsibilities as outlined.. * I agree REFUND POLICY: NO REFUNDS. No refunds if child misses classes due to illness or other reasons. For any withdrawals from Wildflowers class we hope to receive a 30-day notice. * I agree I am aware that Nature School is totally nature-based, and children will be outside in all weather conditions, except under severe temperatures or events. * Yes Acknowledgement and Assumption of Risks: * 1. I understand and acknowledge that the LFNS & Black Ridge Farms programming in which the participant/my child will participate may be physically strenuous and has risks, dangers and hazards including, but not limited to: A. Hazards associated with being outdoors which may include walking/working on steep, slippery or uneven ground, holds, falling tree limbs or rocks, exposure to managed (grown) vegetables and unmanaged plants (those that grow in nature such as weeds, shrubs, trees, berries etc.), exposure to pollens, dusts. B. Unpredictable and changing weather that could result in exposure to sunlight, heat, cold, wet or windy weather, lightning, and animals, including dogs,, deer, elk, rodents, snakes, birds, tics, insects, bees, spiders, etc .C. Hazards associated with using hand tools and hammers, tweezers, scissors .D. Hazards associated with being around a wood stove. E. Hazards associated with being in or around a farm. F. Hazards associated with gardening such as lifting, bending, carrying buckets of produce and using hand tools such as shovels, hoes, trowels, shears and scissors and equipment such as ladders, wheel barrels, buckets, baskets, rope, wire, gloves, etc. G. Hazards associated with having direct contact with organic materials such as composted materials, food, scraps, earth, manures, worms, etc. H. Hazards associated with becoming separated from guides or companions and in inability to communicate or access rescue and medical help. I. Theft, vandalism or loss of personal property. J. Hazards associated with farm animals, cows, sheep, rabbits, chickens, cats and dogs. 2. I acknowledge that participating in the LFNS program involves inherent risks and other risk hazards and dangers, including some not listed above that can cause or lead to death, injury, illness, property damage or loss, mental or emotional trauma, or disability. 3. I have been informed of my right to obtain as much information about this program activity from LFNS as I feel necessary, including information beyond that information provided to me herein respecting the nature and the extent of risks and hazards associated with the program or activity and I acknowledge that I am satisfied with the information provided to me. 4. I agree LFNS shall not be responsible for any adverse health or medical conditions of my child. 5. In entering into this Agreement I am not relying upon any oral or written representations or statements made by the Released Parties other than what is set forth in this Agreement. 6. I freely and voluntarily agree to assume all of the risks of the activities of my child’s Nature School program whether inherent or not and whether described above or not and understand any acknowledgement that my child, as a participant may suffer personal and potentially serious injury due to an unforeseeable or fortuitous event. I agree Release of Liability * 7. Liability Release and Indemnity Agreement. I hereby release, indemnity and hold harmless LFNS & Black Ridge Farms and each of its respective employees, officers, independent contractors, subcontractors, volunteers and all other persons or entities acting for or under the discretion and control of LFNS, Black Ridge Farms and agree to waive any and all claims that my child or I have or my spouse or other parent or successors or assigns have or may have in the future against the Released Parties for, any loss, damage, injury, claim or expense in any way associated with my child’s participation in the LFNS, Black Ridge Farms program or the use of any equipment or facilities. Neither I nor anyone acting on my or my child’s behalf will make a claim against the Released Parties as a result of injury, illness, damage, death or loss to person or property, whether arising from negligence, breach of contract or breach of any statutory or other duties of care, including any duty of care owed under the Occupiers Liability Act or similar law for the exemption of liability on public and/or recreational lands. I further agree to hold harmless and indemnify the Released Parties from any and all liability for any damage to the property or, or personal injury to any third party, including other participants in the program resulting from any child’s participation in the program. I have read this Release of Liability and Assumption of risk, fully understand its terms, understand that I have given up substantial rights by signing it and sit it freely and voluntarily without any inducement. I agree that this form shall be binding on me, my minor and/or adult children participants, my spouse or partner and other family members, my heirs, executors, representatives, successors and assigns. I hereby confirm that I have legal authority to act on my child’s behalf. I agree on my own and on my child’s behalf to the terms and conditions in this document. By selecting I AGREE below, you have read and agree with the terms outlined above. I agree Your Signature * By signing your name below you agree to all stated above. Date MM DD YYYY Thank you! You’ll be hearing from me soon!
