Hive Participation Form

Hive Participation Membership Form

Please submit a form annually for each Family participating in Anie's Hive membership, programs, and activities.
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender
Child 2's Name

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender
Child 3's Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
List any additional children and their date of birth
Primary Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Parent/Guardian Name*

First NameLast Name
Email Address*
example@example.com
Cell Phone Number*

Area CodePhone Number
Parent/Guardian Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Email Address
example@example.com
Cell Phone Number

Area CodePhone Number
Parent/Guardian Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Emergency Contact 1*

First NameLast Name
Relationship to child*
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2

First NameLast Name
Relationship to child
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information
Please list any Allergies (food and/or medication) noted with individual's name or comment none if your family has no known allergies*
Please list any family dietary restrictions, sensitivities, lifestyle choices or preferences the Hive should consider for your participation.
Please note any other information you think we may need to know to make your participation in the Hive a fulfilling experience.
Policy, Permissions and Agreements
Photo and Video Release (optional)

By checking this box, I give Stephanie and Michael Buzzell permission to share photos/videos via electronic messaging platforms (email, text, messaging apps, etc). These photos/videos may be emailed or messaged to parent/guardians for updates about child's day. These photos will NOT be used for any display or marketing material without further consent.By checking this box, I give further permission for Stephanie Buzzell to display photos of my child at Anie's Hive on Anie's Hive website or facebook page for gallery and marketing purposes.
By checking each box below, I indicate I have read and understand:*

I am responsible for the supervision of my child while participating in Hive membership programs and activities. I agree to remain on the premises at all times my child is participating (unless additional care enrollment form has been submitted). I understand I may send my child with an alternative adult and that said responsible adult is bound by our family's membership permissions, policies, and agreements.Anie's Hive health and wellness policies. There are risks (and benefits!) of Hive membership, programs, and activities and community and nature play. I understand I am solely responsible for the well-being of my family and will refrain from Hive community attendance if at any point I feel it is not best for my family/child. I will respect the personal decisions of other Hive members.Anie's Hive will consider member input regarding policy at an annual membership meeting. I understand policy updates outside of annual updates may occasionally be necessary. Generally, though not required, a membership input meeting will be announced with at least 24 hours notice. Final policy updates are at the discretion of Stephanie Buzzell and all policy changes will be announced with at least 48 hours written notice to all members. Members may revoke Hive membership at any time.
I, First Name* Last Name* and First Name Last Name certify I/we am/are the legal parent/guardian(s) of List child(ren)'s name(s) and as such voluntarily enroll for permission for my child and I to participate in Hive membership, programs and activities. I understand that there are risks associated with our participation in Hive membership, programs, and activities, such as physical and/or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, death or economic loss. These injuries or outcomes may arise from our own or other's actions, inactions or negligence or the condition of activity location or facilities. Nonetheless, I assume all risks of our participation in Hive membership, programs and activities, whether known or unknown to me. In consideration for being allowed to participate in Hive membership, I release Stephanie Buzzell, Michael Buzzell, Anie's Hive, their employees, volunteers and associates from any and all liability associated with participation in Hive membership, programs, and activities. I agree to hold harmless from any and all claims, loss or damage to our personal property, liabilities and costs, including attorney fees, as a result of our participation and membership. I understand I am financially responsible for any emergency care charges and/or all treatment charges incurred by participation in Hive membership, programs and activities.
Parent/Guardian Member Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Member 2 Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Hive Participation Membership Form