Junction Farm

Junction Farm Waiver

2800 S English Station Rd, Louisville, KY 40299
Participant Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Contant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Informed Consent and Acknowledgement

I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Junction and Serendipity KY 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 camp sessions.

In case of injury, I hereby waive all claims against the Junction and Serendipity KY including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of any 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, x-ray examination and immunizations for the named athlete. 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 Junction and Serendipity KY and its affiliates including Directors and Staff to provide the needed emergency treatment prior to admission to the medical facility.

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 participants for this event.
Lake Activities

By entering the premises and/or participating in swimming or water-related activities in or around the lake, you acknowledge and agree to the following terms:

Swimming in natural bodies of water such as lakes involves inherent risks and dangers, including but not limited to: drowning; slips, trips, and falls; underwater hazards such as rocks, debris, or sudden drop-offs; strong currents; exposure to cold water or inclement weather; waterborne illnesses; encounters with wildlife; and the absence of lifeguards or immediate medical assistance.

By choosing to swim in the lake, you voluntarily assume all risks associated with this activity, whether known or unknown and you hereby agree to release, waive, discharge, and hold harmless the property owner(s), management, agents, employees, volunteers, and any affiliated organizations (collectively, the “Released Parties”) from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, injury, or death that may occur as a result of your use of the lake, including but not limited to any negligence or omission on the part of the Released Parties.

This agreement is intended to be binding upon you, your heirs, executors, administrators, assigns, and any legal representatives.

DO NOT ENTER THE WATER unless you fully understand and accept the risks outlined above. Swimming is at your own risk in the absence of a Life Guard.
Livestock

REGISTRATION OF PARTICIPANTS AND AGREEMENT PURPOSE. By signing this agreement, I and the parent or legal guardians there of if a minor, do hereby agree to hold harmless the Junction and Serendipity KY for the purpose of livestock education and activities. I acknowledge that my child will be inside pens and barns among livestock (goats, horses, donkeys, dogs, pigs, bunnies) where the livestock is not restrained and I accept fully acknowledge that injury can incur today and on all future dates.
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*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Junction Farm Waiver

Participant Information