Registration Form SUMMER
A special note from Tina: I am so excited to play and learn with you this Summer! Following the Tinkergarten creativity curriculum and Cedarsong Way Teachings, we'll meet weekly for purposeful outdoor play, songs, movement, and community time. I cannot wait to connect with you and your family! Questions? Learn more about our curriculum at https://www.wilddragonflyexplorers.com/ or email me: wilddragonflyexplorer@gmail.com.
Parent information
Name of Purchasing Adult
*
First Name
Last Name
Name of Adult Attending Class
*
First Name
Last Name
Email for Class Communication
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Explorer(s) information
Name of Explorer
*
First Name
Last Name
Explorer's Date of Birth
*
-
Month
-
Day
Year
Date
Name of Second Explorer (if applicable)
First Name
Last Name
Second Explorer's Date of Birth (if applicable)
-
Month
-
Day
Year
Date
Name and Date of Birth of any additional explorers (if applicable) **Ex: Vlad (5), Lily (4)**
PHOTO RELEASE
May I include photos/videos of you and your explorer(s) on social media? (in publications, news releases, online, & other communications related to Wild Dragonfly Explorers)
*
Yes, you may include photos/videos of my child(ren)
No, but you may take some during class to share privately with me later.
No, please refrain from taking photos/videos of our family.
Allergies/Health
Please list any allergies or health concerns that we should be aware of. If there are none, you may write N/A. If there are any other important details that you wish to include, please share them with me here.
*
Release of Liability
The teacher, Tina Nillissen, is committed to every explorer's safety and carefully assesses and manages danger and all of our activities. However, there are risks associated with any youth activity. Each child must submit this form in order to participate.
Read Carefully - THIS IMPACTS YOUR LEGAL RIGHTS
1. AGREEMENT TO FOLLOW DIRECTIONS
I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Tina Nillissen.
2. ASSUMPTION OF THE RISKS AND RELEASE
ASSUMPTION OF THE RISKS AND RELEASE. I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Tina Nillissen for injury, loss or damage arising out of my or my family's use of or presence upon the facilities of Tina Nillissen, whether caused by the fault of myself, my family, Tina Nillissen or other third parties.
3. INDEMNIFICATION
I agree to indemnify and defend Tina Nillissen against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family's use of or presence upon the facilities of Tina Nillissen.
4. FEES
I agree to pay for all damages to the facilities of Tina Nillissen caused by any negligent, reckless, or willful actions by me or my family.
5. MEDICAL AUTHORIZATION
In the event of an injury to the above minor during the above described activities, I give my permission to Tina Nillissen or to the employees, representatives or agents of Tina Nillissen to arrange for all necessary medical treatment for which I shall be financially responsible. This temporary authority will begin on February 01, 2024 and will remain in effect until terminated in writing by the undersigned or when the above described activities are completed. Tina Nillissen shall have the following powers: a. The power to seek appropriate medical treatment or attention on behalf of my child as may be required by the circumstances, including without limitation, that of a licensed medical physician and/or a hospital; b. The power to authorize medical treatment or medical procedures in an emergency situation; and c. The power to make appropriate decisions regarding clothing, bodily nourishment and shelter.
6. APPLICABLE LAW
Any legal or equitable claim that may arise from participation in the above shall be resolved under Minnesota law.
7. NO DURESS
NO DURESS. I agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire. I further agree and acknowledge that Tina Nillissen has offered to refund any fees I have paid to use its facilities if I choose not to sign this Agreement.
8. ARM'S LENGTH AGREEMENT
This Agreement and each of its terms are the product of an arm's length negotiation between the Parties. In the event any ambiguity is found to exist in the interpretation of this Agreement, or any of its provisions, the Parties, and each of them, explicitly reject the application of any legal or equitable rule of interpretation which would lead to a construction either "for" or "against" a particular party based upon their status as the drafter of a specific term, language, or provision giving rise to such ambiguity.
9. ENFORCABILITY
The invalidity or unenforceability of any provision of this Agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not affect the validity or enforceability of any other provision of this Agreement or of any other applications of such provision, as the case may be, and such invalid or unenforceable provision shall be deemed not to be a part of this Agreement.
10. CONSENT
I consent to the participation of my child/children enrolled in the activity of Tinkergarten Class, and agree on behalf of the above minor to all of the terms and conditions of this Agreement. By signing this Release of Liability, I represent that I have legal authority over and custody of the children listed.
I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.
Please read this release of liability waiver and sign your full name, and write in the full names of the children you are consenting for:
Signature
*
Name of Explorer you are consenting for
*
First Name
Last Name
Names of any additional Explorer(s)
Today's Date
Payment
*
prev
next
( X )
June 25 - Aug 13 (1st Explorer)
Tuesday's 10:00 AM - 11:00 AM
$
175.00
Quantity
1
2
3
4
5
6
7
8
9
10
Additional Sibling Explorer
$
80.00
Quantity
1
2
3
4
5
6
7
8
9
10
Registered Family: Sibling Drop-In
Have another sibling that can only attend a few classes? First two visits are free, after that our drop in fee for registered families is $20 a session.
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
Complete
Complete
Should be Empty: