2024 PLA x Good Roots Camp Forms and Payment

PLA x Good Roots Farm Summer Camp

Summer 2024
Waiver and Release Form for Summer Camp
Liability Release and Parental Consent Form

In consideration of the acceptance of my application for the summer recreation program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to my child as a result of their participation in said summer program. This release is intended to discharge in advance the Prairie Learning Academy (PLĀ), its officials, officers, employees, volunteers, and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release, and assumption of risk is to be binding on my heirs and assignees.
Consent of the Parent or Guardian
I give consent for my child, child(ren)'s name(s)* to participate in the above summer program, and I execute the above liability release on my child’s behalf.
Consent for Treatment
I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that the Prairie Learning Academy (PLĀ) will provide no medical insurance for such treatment, and that the cost thereof will be at my expense.
I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions.
Parent/Guardian Signature*
Name

First NameLast Name

Photo Release Form for Minor Children

I,   First Name   Last Name  hereby authorize the Prairie Learning Academy (PLĀ), Good Roots Farm LLC, and any camp program organization(s) to publish the photographs taken of me and/or the minor children listed below, and our names, for use on any promotional materials, including the internet. I release the Prairie Learning Academy (PLĀ) and the recreation program from any expectation of confidentiality for the minor children and myself and attest that I am the parent or legal guardian of the child or children listed below and that I have the authority to authorize the Prairie Learning Academy (PLĀ) and the recreation program to use their photographs and names. I acknowledge that since participation in publications and websites produced by the Prairie Learning Academy (PLĀ) or the recreation program is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by the Prairie Learning Academy (PLĀ) or the recreation program confers no rights of ownership whatsoever. I release, the Prairie Learning Academy (PLĀ) its officials, agents, volunteers, contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the minor child or children listed below.
Signature of Parent/Guardian:   Signature

Names and Ages of Minor Children:
Child 1:
First Name   Last NameAge
Child 2:
First Name   Last NameAge
Child 3:
First Name   Last Name Age
Additional Children:
First/Last/Age

Does your child (or do your children) have any support needs that our staff should know about? These can be health conditions (such as diabetes, epilepsy, or anaphylactic allergies), disability (for instance, using a wheelchair or other mobility aids), neurodivergence (like sensory integration needs, whether hypo- or hypersensitive), or assistance with daily living skills like toileting. If yes, please describe in the text box below.
YesNoOther

Contact Information

This includes communication about camp and any emergency contact needs.
Primary Contact
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact

(Optional)
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Select how many children you are registering for.
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2024 Camp: Super Hero Camp!
July 22 - 25, 2024 / 9:00-12:30 / 2nd-6th Grade

$90 Number of children
Item subtotal:$0.00
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PLA x Good Roots Farm Summer Camp

Contact Information

Primary Contact

Secondary Contact