Wonder Roots Program Registration

Date *

Date

Name of Participant *

First Name Last Name

Birth Date of Participant *

Date

Address of Participant *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Emergency Contact (Parent/Guardian if participant is a minor) *

First Name Last Name

Phone Number of Emergency Contact *

Area Code Phone Number

Email *

example@example.com

Does the named participant have any medical conditions, allergies, medication or issues or specific developmental needs that we should know about? Please describe: *

Is there any other condition that we should be aware of that may endanger, alter, or somehow limit the named participant's abilities to participate in any Wonder Roots Program? *

I, in my legal capacity as the program partcipant or parent/guardian of the minor participant named, do hereby acknowledge and agree that participation in Wonder Roots LLC activities comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with Wonder Roots LLC participation, including but in no way limited to: (1) Accidents and injuries resulting from the forces of mother nature, (2) live animal and bug interactions, (3) slipping and falling, (4) malfunctioning equipment, (5) unseen obstacles, (6) fatigue, (7) participants’ misjudgment and (8) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with Wonder Roots LLC participation and that said list in no way limits the operation of this Agreement.

COVID-19

I, in my legal capacity as the program participant or parent/guardian of the minor participant named, acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Wonder Roots LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Wonder Roots LLC can not guarantee that COVID-19 infection will not occur through participation in Wonder Roots LLC programs. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself, {nameOf} and others, including, but not limited to, staff, and other Wonder Roots LLC participants and their families.

I voluntarily seek services provided by Wonder Roots LLC and acknowledge that risk to exposure to the Coronavirus/COVID-19 increases by participating in group activities such as that of Wonder Roots LLC. I acknowledge that I and the {nameOf} must comply with all set procedures to reduce the spread while attending Wonder Roots LLC programs.

AFFIRMATION AND LIABILITY RELEASE

I hereby affirm that I have been informed that there are inherent dangers of being outdoors at a nature program.
I hereby agree to indemnify and hold harmless this Wonder Root LLC staff and its owners, volunteers, and workers from any and all liability for any harm, injury, death, or damages (physical, mental, or monetary), regardless of fault or negligence, which may befall me and/or my child while participating in this program or while using facilities. This release shall be binding upon my family, heirs, and administrators.
I hereby agree to heed at all times the advice and instructions of the Wonder Roots LLC staff and its owners to practice common sense while at the nature program.
The participant, if a minor, has my permission as their parent/guardian, to participate in the activities of Wonder Roots programming.

I acknowledge that if anyone is hurt or property is damaged during my or my child’s participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against Wonder Roots LLC on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read the above Wonder Roots LLC Liability Waiver AND Wonder Roots LLC Policies and Procedures in response to COVID-19 in its entirety. I have read & understood it, and I agree to be bound by its terms.

CONSENT FOR MEDICAL TREATMENT: In the event of an emergency requiring medical attention, permission is hereby given for the staff of Wonder Roots LLC programming whom are CPR/first aid certified to administer CPR and/or first aid as deemed necessary. Further permission is given to allow medical services to be performed by doctors, hospitals or other qualified medical providers as deemed necessary in an emergency, including surgery if reasonably necessary. I understand that the cost of all emergency services is my responsibility. Note: If the participant has any medical condition that a Wonder Roots LLC program staff should be aware of it, it is your responsibility to let us know of the existing condition prior to the start of any program. The information will be held in confidence and used only to render assistance should the need arise. *

YES, I have read and consent to medical treatment for the named participant should the need arise.

PHOTO RELEASE: Occasionally photos and video will be taken during program and may be used for Wonder Roots LLC training and publications including its website and social media pages. However, we will not identify the participant by name or release any personal information. *

I do GIVE permission to have photo/video taken of named participant . I do NOT GIVE permission to have photo/video taken of named participant.

Signature of Participant or Parent/Guardian of Minor Participant Named Above *

Clear

Print Name *

First Name Last Name

My Products

Curiosity Connections

February Curiosity Connections $ 75.00

Topic: Forts & Fire Time: 1-5pm. Dates: Thurs. Feb. 4 & 18th Location: 640 Texas Hill Rd. Hinesburg, VT 05461 Ages 8-14

March Curiostiy Connections $ 75.00

Topic: Mighty Maple Time: 1-5pm. Dates: Thurs. March. 4 & 18th Location: 640 Texas Hill Rd. Hinesburg, VT 05461 Ages 8-14

April Curiosity Connections $ 75.00

Topic: Signs of Spring Time: 1-5pm Date: Thurs. April 1, 15 Location: 640 Texas Hill Rd. Hinesburg, VT 05461 Ages 8-14

May Curiosity Connections $ 75.00

Topic: Paper Possibilities Time: 1-5pm Date: Thurs. April 6, 20 Location: 640 Texas Hill Rd. Hinesburg, VT 05461 Ages 8-14

Curiosity Connection Spring Package $ 280.00

Sign up for all 4 months. Time: 1-5pm Dates: Thurs. Feb 4, 18. Mar 4, 18. April 1, 15. May 6, 20. Location: 640 Texas Hill Rd. Hinesburg, VT 05461 Ages 8-14

Total $ 0.00

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Registration Form

Liability Waiver