UTOPIAT FAMILY CAMP
Pilot Week — Parent Consent, Waiver & Media Release
Child's Name:
Child's Age:
Parent/Guardian Name:
First Name
Last Name
Parent Phone:
Format: (000) 000-0000.
Emergency Contact:
Emergency Contact Phone:
Format: (000) 000-0000.
PARENT CONSENT & PROGRAM ACKNOWLEDGMENT
I give permission for my child to participate in UTOPIAT Family Camp Pilot Week.
I understand that this is a free pilot program being offered to a small group of invited families to help UTOPIAT Family Camp test and improve its programming.
Activities may include gardening and nature exploration, yoga and mindfulness, arts and crafts, cooking and food preparation, reading, movement, outdoor play, and other age-appropriate hands-on activities.
I understand that reasonable care and supervision will be provided, but participation in these activities involves ordinary risks such as minor cuts, scrapes, falls, insect bites, allergic reactions, or other accidental injuries. I voluntarily allow my child to participate and agree not to hold UTOPIAT Family Camp, its organizers, property owners, facilitators, volunteers, or workshop providers responsible for injuries or losses resulting from the ordinary risks of participation, except to the extent liability cannot legally be waived.
I authorize UTOPIAT Family Camp to contact me or the emergency contact listed above if needed. If I cannot be reached in an emergency, I authorize reasonable emergency medical care for my child.
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ALLERGIES, DIETARY & MEDICAL INFORMATION
Please list any allergies, dietary restrictions, medications, medical considerations, activity limitations, or other information we should know to help keep your child safe:
If none, write "None."
PHOTO & VIDEO PERMISSION
I give UTOPIAT Family Camp permission to photograph and/or record my child during Pilot Week activities and to use selected photos and videos for future UTOPIAT Family Camp promotional and informational purposes, including its website, social media, digital advertising, printed materials, and presentations.
My child will not be identified by full name in promotional materials without separate permission.
PARENT AGREEMENT
By signing below, I confirm that I am the child's parent or legal guardian, that the information provided above is accurate, and that I have read and agree to the Parent Consent and Program Acknowledgment above.
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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