Liability Waiver & Media Release Form

General Liability Release Forms

For Pacifica: A Garden in the Siskiyous
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To participate in any event or activity at Pacifica: A Garden in the Siskiyous, all attendees must complete and sign this form. These forms will be kept on file indefinitely and apply to all Pacifica events and programs.

Note: A separate form must be completed for each child or dependent participating in a Pacifica event.
Who are you filling these forms out for?*

MyselfMy child/dependent
Child/Dependent Name*
Legal First & Last Name
Name of Person Completing This Waiver*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Liability and Release Forms
I understand that participation in events and activities at Pacifica may involve inherent risks of injury to myself, my child, or dependent, as well as to third parties and spectators. I voluntarily choose to participate and/or allow my child or dependent to participate, fully accepting and assuming all such risks.

In consideration of Pacifica providing access to its programs and facilities, I agree to release and discharge Pacifica, its staff, instructors, officers, agents, and volunteers from any and all claims or liabilities, including those arising from negligence (active or passive), for personal injury, property damage, or other loss incurred by myself or my dependent.

I further agree to indemnify and hold harmless Pacifica from any costs, including attorney’s fees, resulting from claims arising from my or my dependent’s actions during participation.

I acknowledge that Pacifica does not carry medical insurance for participants and that any existing insurance coverage does not affect the validity of this release.

I understand that this release prevents me from pursuing legal claims against Pacifica for injuries or damages related to participation in its programs.
Emergency Medical Authorization
In the event of illness or injury during a Pacifica program or activity, I authorize Pacifica staff, agents, or representatives to obtain necessary medical treatment for myself and/or my child or dependent.

I understand that a reasonable effort will be made to contact me or my designated emergency contact prior to treatment. If I cannot be reached, I give consent for emergency medical care, including hospitalization, anesthesia, or surgery, as deemed necessary by qualified medical personnel.

I accept full financial responsibility for any medical services rendered.
Emergency Contact Name*
Relationship to Participant*
Phone Number*
Please enter a valid phone number.
Medical Notes (Allergies, Medications, Special Health Concerns)
Student Supervision and Behavioral Needs
Due to the nature of our programs, which may involve various physical activities and an increased level of risk, we may face challenges in supporting students with specific behavioral or emotional needs. While we are committed to providing a safe and enriching experience for all participants, the level of supervision and individualized support required for children with such needs may exceed our current staffing capacity.

We encourage families to email us at education@pacificagarden.org to discuss their child’s specific needs in advance. This will allow us to assess whether our program is a suitable fit.

Please note that we reserve the right to unenroll a student if their behavioral challenges or supervision needs disrupt the class or exceed what our staff can reasonably provide. In such cases, parents or guardians will be required to withdraw their child from the program.
Media Release
I understand that photographs and videos may be taken during Pacifica events in which I and/or my child or dependent may appear. These images may be used to promote Pacifica’s programs through social media, printed materials, local news, and the Pacifica website.

Personally identifiable information, including names, will only be used with additional written permission if the individual is over 16 or from a parent/guardian if the subject is a minor.
Name of Participant*

First NameLast Name
By signing below, I acknowledge that this typed or electronic signature is legally binding.
Typed Name of Person Completing Form*
Date*

MonthDayYear
Date
Should be Empty:

General Liability Release Forms

Liability and Release Forms

Emergency Medical Authorization

Student Supervision and Behavioral Needs

Media Release

By signing below, I acknowledge that this typed or electronic signature is legally binding.