2019 Power of Produce (PoP) Club Registration

Child's Name *

First Name Last Name

Child's Age *

Parent/Guardian's Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Email *

example@example.com

PoP Club Location *

Rock Rapids Farmers' Market Sheldon Farmers' Market

Please read the below RELEASE AND WAIVER OF LIABILITY and PUBLICITY RELEASE, and electronically sign and date to confirm your parental/guardian consent. This affects any rights you may have if you or your child/children participate in the Power of Produce (PoP) program.

RELEASE AND WAIVER OF LIABILITY

Iowa State University

Power of Produce (PoP Club)

I, as parent of participant(s), understand that there could be risks to youth participating in the PoP program. I understand that there will be ISU Extension and Outreach staff and interns present each time and they will do their best to supervise participants, but I am responsible for my child while they participate in PoP activities. I understand that the PoP activities are ‘come and go’, lasting between 10 and 20 minutes. I understand my child should not be left longer than 30 minutes.

I hereby RELEASE FROM LIABILITY, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the State of Iowa, the Board of Regents State of Iowa, Iowa State University, Iowa State University Extension, Lyon County Extension, employees or volunteers of the above-mentioned entities (hereinafter referred to as RELEASEES) for any liability, claim and/or cause of action arising out of or related to any loss, damage or injury, including death, that occurs as a result of participating in PoP activities.

I agree TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES whether injury or damages are caused by my negligence, the negligence of the RELEASEES or the negligence of any third party. I further agree that this Release and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives (if any), if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named

RELEASEES. I hereby further agree that this Release and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Iowa.

By signing this release of liability, I state that I have read and understand the conditions set forth in this release and that I agree to all conditions set forth herein, and that I sign this voluntarily with full knowledge that I am forfeiting certain legal rights.

PUBLICITY RELEASE

By electronically signing below, I also give permission to ISU Extension and Outreach to photograph, film, audio/video tape, record and/or televise my child's image and/or voice for use in any publications or promotional materials, in any medium known or developed in the future without any restrictions.

Parent/Guardian's Electronic Signature *

Date of Electronic Signature *