Community Garden Registration Form

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender

MaleFemale

Grade

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

Grade

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

Grade

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

Grade

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

Grade

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Home Number*

Cell Number

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe for any/all children.

Is the child prescribed an inhaler or any medication? If yes, please explain any instructions for any/all children.

Informed Consent and Acknowledgement

I hereby give my approval for my child/children participation in any and all activities prepared by BOnPurpose. In exchange for the acceptance of said child/children candidacy by BOnPurpose, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless BOnPurpose and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said child/children, I hereby waive all claims against BOnPurpose including all mentors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There may be risk of being injured that is inherent in any/all activities.

Medical Release and Authorization

As Parent and/or Guardian of the child/children, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment and x-ray examination for the named child/children. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the BOnPurpose and its affiliates including Directors, Mentors, Volunteers, and Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered program.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date*

Date

Signature*

Community Garden

Participant Information