Single Day Event Request
Field Trips, Church Picnic, Birthday Parties, Baptisms, Anniversay Parties, Baby Showers, Etc.
General Details
Contact Name
*
example@example.com
Organization Name
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Location Request
*
Farm House Yard
Baptismal Area
Barn
Picnic Shelters
Chapel
Kitchen Shelter
Swimming Hole
Gazebo
Cabin
Hickory Suites
Cottage
Campfire Pit
Stage
Other
Event
*
Baptism
Birthday Party
Baby Shower
Church Picnic
Party, Other
Youth Group Outing
School Field Trip
Company Picnic
Wedding
Graduation Ceremony
Other
Additional Details
Requested Event Start Date & Time (This is not a confirmation)
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Requested Event End Day & Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Attendee Details
Estimated Number of Adult Attendees
*
Estimated Number of Child Attendees
*
Agreements
If you are requesting a trip for an organization, does your organization carry insurance for events?
*
Yes
No
Is your event sponsored by a church, school, or nonprofit organization?
*
Yes
No
Trip Sponsor's Signature
Liability Waiver, Use of Facilities, Clinch River Farms:I understand and acknowledge that Clinch River Farms and all of the activities taking place at said farm are considered agritourism. Certain activities may be dangerous and could cause injury. I do hereby hold harmless Clinch River Farms, Clinch River Ministries, and Lexcite Corporation, its Board of Directors, employees, and assigns, and any property owner on which we are allowed to enter to perform these activities, and further understand that my signature hereon holds these persons and entities free from any and all liability associated with my participation in the above-referenced activities. With the knowledge of the foregoing, I hereby agree to waive or release any and all rights that I or my heirs may have to make a claim against any members of the Board of Directors, employees and participants, Lexcite Corporation, Clinch River Farms, Richard Hudson or any other person, arising from any damages, injury, or death a participant might sustain or which might occur as a result of participation. I further agree to indemnify and hold harmless all of the foregoing from any claims which I might make or which might be made on my behalf by others or which might be made against me by others, arising from my participation. Furthermore, I agree to indemnify the Board of Directors, members or employees, or any landowners, their families, employees or tenants, for any injury, death, loss or any other arising from any sponsored activities.1 In consideration of my/my child’s/my ward’s/my organization's attendance and participation at all associated activities and outings (collectively known as “the farm”), I, individually and on behalf of my child/ward/organization, hereby enter into this agreement and accept all of its terms. I represent and agree that I have the legal capacity and authority to act for and on behalf of my child/ward/organization. 2 Beginning on the first day of my or my child/ward’s/organization's presence at, attendance and/or participation in the Farm and continuing from day to day throughout the time I and/or my child/ward/organization is present at, attends, and/or participates in the Farm, I hereby authorize any licensed physician, emergency medical technician, paramedics, nurses, hospital or other medical or health care facility or provider (“Medical Provider”) to provide medical care to my child/ward/individual related to the organization for any illness, injury, and/or condition that occurs, manifests or arises at the Farm. I further authorize any such Medical Provider to perform all procedures or services deemed medically advisable to treat or relieve, or to attempt to treat or relieve, any illness, injury, and/or condition. 3 I execute this Consent for Medical Treatment (the “Consent”) with Lexcite Corporation, its parent, subsidiaries, related and affiliated entities, officers, directors, partners, shareholders, employees, members, agents, insurers, successors and assigns. I understand and agree that this Consent shall be binding on me and my child/ward/organization, as well as the representatives, executors, heirs, next of kin, administrators, beneficiaries, successors and assigns of my child/ward/organization. 4 I authorizeLexcite Corporation, its parent, all subsidiaries, related and affiliated entities, to share medical information related to my child/ward/individual from my organization with any Medical Provider providing medical care to my child/ward for any illness, injury, and/or condition that occurs, manifests or arises at the Farm. 5 I acknowledge that there is a risk of complications and unforeseen consequences in any medical treatment and I, individually or as parent/natural guardian of my child/ward, a minor, sign this Agreement on behalf of my child/ward/organization. 6 I acknowledge that no warranty is being made as to the result of any medical treatment. I agree that any health history provided by me or my child/ward is correct to the best of my knowledge. 7 I acknowledge having knowledge and experience with the health and capabilities of my child/ward/organization superior to Farm staff. I certify that my child/ward is in good health and does not have any health or mental / physical impairments or conditions that would be aggravated by attendance or participation at the Camp or that make such attendance or participation unsafe or otherwise inappropriate for my child/ward/organization, the animals at the Farm, staff, or other campers. I further certify that my child/ward/individuals from my organization does not currently have upper respiratory disease or illness (including but not limited to colds, flu, etc.), is not on medication that suppresses immune function or has possible side effects that would interfere with the Farm, and that my child/ward does not have open sores, open wounds, cuts, abrasions, skin irritations or other outward signs of illness.
*
Please Select
I agree
I do NOT agree
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