Roots to Rise Registration

• We are excited to invite youth grades K-8 to join us at Roots to Rise camp from July 10-14, 2023, 9am - 3pm each day. 

• We will host camp at the Ponca Bulding at 1701 "E" Street. Families will need to provide their own transportation to and from Roots to Rise.

Parent/Guardian Information

Emergency Information

WARNING OF RISK, WAIVER AND RELEASE OF ALL CLAIMS FOR ROOTS TO RISE BY STAND IN FOR NEBRASKA

For and in consideration, the undersigned parent(s) or guardian(s) of the participant in the Roots to Rise Program, I/we recognize and acknowledge that there are certain risks of physical injury and I/we agree to assume the full risk of any injuries, including death, or loss which the undersigned or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program. I/we do hereby declare that I/we waive all claims of whatsoever kind or nature against Stand in for Nebraska, its officials, officers, agents, employees, and volunteers and Ponca Tribal Nation from any and all claims arising from injuries, including death, damage or loss which I/we or my minor child/ward may incur or may accrue to me or my minor child/ward on account of participation in the activities of this program. I/we further agree to indemnify and hold harmless and defend Stand in for Nebraska its officials, officers, agents, employees, and volunteers and Ponca Tribal Nation from any and all claims resulting from injuries, including death, damages and losses sustained by the undersigned or my minor child/ward or resulting of this program. This shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I/we have read and understand the above Warning of Risk Waiver and Release of All Claims, and understand the effect of the relinquishment of rights hereby waived. By signing below I give permission for my child to participate in program activities. I understand that Stand in for Nebraska does not carry health and accident insurance for my child, and that I as guardian will be responsible in case of injury where bills are incurred. I understand that my child may be dismissed for failure to follow rules and failure to follow general operating procedures of the program. As a parent/guardian, I will work as a partner with staff to ensure my child is successful in the program. The information I have listed is correct to the best of my knowledge and I will notify the program staff of any changes to the information in a timely manner.

MEDIA RELEASE PERMISSION GRANTED TO: STAND IN FOR NEBRASKA

I, the undersigned, hereby authorize Stand in for Nebraska, including its assigns and agents, to use my child's name, statements, image, voice, videos, or likeness for the purpose of promotion or public information without obtaining further consent or without prior knowledge of such use. I understand that the statements, image, voice, videos, or likeness may be altered as required for publication or distribution. I hereby release and hold harmless Stand in for Nebraska, its successors, assigns, directors, agents, officers, and employees for any violation of any personal or proprietary right or any other claims I may have in connection with such use. I have the full right and legal capacity to sign this consent and release. I have read this consent and release prior to signing it, and I understand its contents.

Thanks for all that information that helps us manage the camp and have a safe environment! If you've completed the form, you can submit it now.