Earth School at Volusia Tea Garden Parent/Guardian Supervised Child Registration

Please fill out a separate registration form for each child under age five, including babies-in-arms, who will be present.

Child’s Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Age

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Other Parent/Guardian Information (optional, if other Parent or Guardian will bring your child)

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship to Child

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

I acknowledge that I will be present with and primarily responsible for the listed child for the duration of each class.

Photo and Video Release

I hereby grant on behalf of myself (or my minor child as their parent or guardian), to Volusia Tea Garden the right and permission with respect to photographic images and video taken of me/my child at Volusia Tea Garden and its programs. I allow Volusia Tea Garden to use these images in it’s brochures, websites, and any other media for legitimate business purposes and grant Volusia Tea Garden ownership of these images and waive liability relating to their use. This permission I am granting extends from the present date forward. I may revoke this permission in writing at any time.

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.

Signature

Informed Consent and Acknowledgement

I hereby affirm that I am voluntarily participating in activities at Volusia Tea Garden. I am voluntarily participating entirely at my own risk. In full consideration of the risk of injury while participating in agritourism activities at Volusia Tea Garden, I hereby give my approval for my child’s participation in any and all activities prepared by Volusia Tea Garden. In exchange for the acceptance of said child’s participation at Volusia Tea Garden, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Volusia Tea Garden 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 class sessions. In case of injury to said child, I hereby waive all claims against Volusia Tea Garden, including all instructors and affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any kind of risks related to traveling to and from as well as participating in the Program, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness disfigurement, temporary or permanent disability, economic or emotional loss, and death. I acknowledge that I have carefully read this form and fully understand that it is a release of liability. I expressly agree to release and discharge Volusia Tea Garden and its instructors from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action for injury or property damage.

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.

Signature

Medical Release and Authorization

As Parent and/or Guardian of the named child, 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. This authorization is granted only after a reasonable effort has been made to reach me. Release authorized on the dates and/or duration of the registered season. 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.

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.

Signature

Agritourism Acknowledgement

Under Florida law, an agritourism operator is not liable for injury or death of, or damage or loss to, a participant in an agritourism activity conducted at this agritourism location if such injury, death, damage, or loss results from the inherent risks of the agritourism activity. Inherent risks of agritourism activities include, among others, risks of injury inherent to land, equipment, and animals, as well as the potential for you to act in a negligent manner that may contribute to your injury, death, damage, or loss. You are assuming the risk of participating in this agritourism activity.

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.

Signature