Spring 2022 Community Clinic Form

Welcome to the Outdoor Connection's Kids Fishing Clinic Registration Form

Provided by OutdoorConnections
This Fishing Clinic is designed to introduce children to fishing and hopefully cultivate a new passion for the Outdoors and Marine Conservation. Upon completion of the clinic, children will take home complimentary rods, reels, and tackle boxes. This event will take place at our adventure hub, the Virginia Key Outdoor Center.

Here are some improtant things you need to do before completing this form:

1) The Child being registered for the Outdoor Connection's Kids' Fishing Clinic must reside in the City of Miami. (Parent/Legal Guardian must provide proof of residency)

2) The Child being registered for the Outdoor Connection's Kids' Fishing Clinic must between the ages of 7 to 12 years old.

3) Parents must submit one registration form per child.

4) Each Child must submit a video of no more than 1 minute long explaining why they would like to go fishing and how they would benefit from attending the fishing camp.

5) The Submission deadline for the May 28thh Fishing Clinic will be on Friday, April 15th at 5:00 PM EST . Each applicant will receive an email letting them know if they have been selected or not for the Fishing Clinic on Wednesday, April 20th.

5) Registration will automatically close at 50 applicants.

Completion of this Registration does not guranatee participation in the Fishing Clinic.

1. Parent or Legal Guardian information

Please fill out the below information.
Full Name*

First NameMiddle Initial Last Name
E-mail*
Phone Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Address*

Street Address

Apt/Suite #

CityState

Postal / Zip CodeCountry
Please provide 2 proofs of residency (ex. Drivers License, Utility Bill, Posted Mail with Parent/Legal Guardian Name)*

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3. Date Selection

Please fill out the below information.
Which Fishing Clinic date are you applying to? If both, select both. Please note that your child will only be granted admission to one date if chosen.*

Saturday, May 28th

3. Child Information

Please fill out the below information.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Grade*

How experienced are they in fishing?*

	1	2	3	4	5

1 is Inexperienced, 5 is Experienced

Allergies or Dietary Restrictions?*
Participant Skils*

Can Swim ProficientlyCannot SwimSwim with assistance
Please submit a video of your child explaining why the child would like to go fishing and how they would benefit from attending the Fishing Clinic. This video cannot be longer than one minute.
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.mov, .mp4, etc Cancelof

4. Emergency Contact

Please follow the below instructions.
Emergency Contact #1*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation to Child*
Are they Authorized to Pick up the Child at the end of the Fishing Clinic?*

YesNo
Emergency Contact #2*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation to Child*
Are they Authorized to Pick up the Child at the end of the Fishing Clinic?*

YesNo
Emergency Contact #3

First NameLast Name
Phone Number

Area CodePhone Number
Relation to Student
Are they Authorized to Pick up the Child at the end of the Fishing Clinic?

YesNo

4. Release Form

Please follow the below instructions.
RELEASE, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT

I, as parent and/or legal guardian of the enrolled participant agree and understand that kayaking, paddleboarding, watersports, mountain biking, swimming, and fitness are HAZARDOUS activities. I recognize that there are risks inherent in these sports hereinafter designated as “THE PROGRAM” including but not limited to, paralyzing injuries and death. Aware of the hazardous of these activities I certified that I will carry my own personal insurance to cover any damage that I as a participant and/or as a parent/legal guardian of the participant (he/she) may have suffered or sustained, or may sustain in the future as a result of the above described activity.

The participant and/or parent/legal guardian hereby agrees to participate in “THE PROGRAM” and hereby agrees to releases, forever discharge, indemnify and hold harmless OutdoorConnections, Virginia Key Outdoor Center, and the City of Miami, its coaches, instructors, officers, directors, staff, volunteers, and their insurers, successors, representatives, assigns, employers, employees, principals, associates, and any all other persons, firms, organizations, and/or corporations who are having any interest or liability in the premises, they being hereinafter designated as the “RELEASES”, either directly or indirectly, of and from any and all action, causes of action, claims, demands, losses, injuries, expenses and damages of every type, kind and character whatsoever which have heretofore been sustained or which may hereafter be sustained by the participant while participating in “THE PROGRAM”.

The participant and/or parent/legal guardian also agrees to indemnify OutdoorConnections, Virginia Key Outdoor Center, The Paddle House, and the City of Miami, for any damages incurred arising from any claims, demand, action or cause of action by the participant.

The paragraph above applies to the premises where “THE PROGRAM” will be carrying out as well as the owner, tenants, managers, or any other person involved with the premises and owners/tenants directly or indirectly.

The participant and/or the parent/legal guardian authorize representatives of OutdoorConnections, Virginia Key Outdoor Center and the City of Miami to secure emergency treatment (call 911) in the event of any medical emergency during their participation in “THE PROGRAM. Further, the participant and/or parent/guardian agree to pay all costs associated with medical care and transportation for the participant.

Further I agree to allow my child and/or the ward’s image, video, photos or any file likeness to be used for any legitimate purpose (Program Advertising, TV Documentary, Testimony) by OutdoorConnections, Virginia Key Outdoor Center, The Paddle House, and the City of Miami and/or its coaches, instructors, officers, directors, employees, principals, associates, firms and organizations.

In executing and delivering this release, the undersigned rely wholly upon his/her own judgment, knowledge and belief as to the nature, extent and duration of the damage which the enrolled child may have suffered or sustained, or may sustain in the future as a result of the above described activity. As to the question of liability involved, the undersigned have exercised his/her right to legal counsel. The undersigned further represent and warrant that he/she has not been influenced by any representations, statements, or warranties made by any person, firm, association, partnership, or corporation hereby released, or by any agent or other person representing concerning the nature, extent or duration of the damage or losses or legal liability therefore.
I hereby acknowledge, accept, understand and agreed to the terms of this release as set forth herein, as it applies to my child/ward.
Name

First NameLast Name
Signature

Clear

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Welcome to the Outdoor Connection's Kids Fishing Clinic Registration Form

1. Parent or Legal Guardian information

3. Date Selection

3. Child Information

4. Emergency Contact

4. Release Form

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