Friends' Flickers Scholarship 2022/23
Youth
*
First Name
Last Name
Age
*
Parent/Guardian
*
First Name
Last Name
Email
*
All program correspondence will be sent to this email.
Phone Number
*
We will call this number for any questions or updates.
Format: (000) 000-0000.
This is a need-based scholarship program. Please mark which annual income category most accurately fits your family.
*
$0 - $40,000
$40,000 - $60,000
$60,000 - $80,000
$80,000 or higher
Which cohort would you like to enroll in?
*
McNear Elementary Fall 2022
McKinley Elementary Fall 2022
Grant Elementary Fall 2022
Emergency Information
Please fill in the information below for the 1st person you would like us to call in case of emergency.
Emergency Contact
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Alternate Phone Number
*
Format: (000) 000-0000.
Medical Information
Does your child have any allergies or medical conditions that we should be aware of?
*
Health Care Providor
Medical Identification Number
Name and Phone # of Child's Physician
Is there anything you would like to share about your child to help them have a successful time in Nature Immersion?
Permission to vaccinate or inoculate (for anti-venom or epi-pen for allergic reaction ONLY)
YES
AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR I do hereby authorize ‘FOPR’’ Staff, to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the California Medical Practice Act, whether such diagnosis or treatment is rendered during an “FOPR” outing by said health care provider at the outing location, the provider’s office, a hospital, or other location. This authorization also applies to dental care under a duly licensed dentist. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the afore mentioned physician in the exercise of his/her best judgment may deem advisable; and neither said agent or any organization involved assumes any financial responsibility for exercising this action. The undersigned also releases “FOPR”, and its agent, from all claims which may develop or accrue to me, or the minor for whom this authorization is intended to benefit, on account of, or reason by of, any injury, loss, or damage which may be suffered by me or the minor as a result of the exercise of this consent, and I hereby assume and accept the full risk and danger of any injury; hurt or damage that may occur as a result of the use of exercise of this consent. This authorization is given pursuant to the provision of Section 6910 of the Family Code of California and shall remain effective until revoked in writing and delivered to said agent(s).
YES
LIABILITY & COVID RELEASE I recognize the element of risk involved in any physical activity associated with the outdoors, especially when undertaken in the company of amateurs. I understand the volunteers do not represent themselves as outdoor professionals and they may or may not have extensive experience.I am aware that my participation in these activities may be physically demanding and potentially hazardous, involving risk of injury, death or personal property loss or damage. The risks included injury or fatality due to immersion in underwater, impact with submerged or exposed objects, slipping and falling, accident or extremes or inclement weather, accidents while travelling to and from activity sites and other risks that may not be known. I am also aware that weather and water conditions are unpredictable and may pose hazards.I acknowledge and assume these risks, both known and unknown, including those arising out of acts of negligence on the part of FOPR, and I wish to participate in this activity. I state that I am free of any medical condition that might create undue risk in me or others who might depend on me in these activities.I 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 Friends of the Petaluma River has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that Friends of the Petaluma River can not guarantee that I will not become infected with the Coronavirus/Covid-19. 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 and others, including, but not limited to, salon staff, and other salon clients and their families.I voluntarily seek services provided by Friends of the Petaluma River and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.I attest that:* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.* I have not traveled internationally within the last 14 days.* I have not traveled to a highly impacted area within the United States of America in the last 14 days.* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.Acknowledging these risks and in consideration for being permitted to participate in this activity, I hereby voluntarily WAIVE, RELEASE, AND DISCHARGE ALL CLAIMS OF LIABILITY for injury, death, property damage, or other loss that I may have at any time in the future against Friends of the Petaluma River as a result of my participation in these activities, even in the claim is due to the negligence of the leaders. I assume full responsibility for all such damage and loss and INDEMNIFY AND HOLD HARMLESS Friends of the Petaluma River for such damage and loss. I agree that this assumption of risk and release shall bind my heirs, executors, and other legal representatives and all members of my family.This assumption of risk and release shall apply to the Friends' staff, event coordinators, and all of their affiliates, employees and agents, and the sponsors of the event.I am aware that by signing this document I AM GIVING UP IMPORTANT LEGAL RIGHTS. I UNDERSTAND THIS and do so of my own free will.
YES
Submit
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