Loading...

TODAY'S DATE: August 12, 2024

PURPLE ASPARAGUS IS COMING TO YOUR SCHOOL!

What is Purple Asparagus?

Purple Asparagus is a nonprofit that educates thousands of children, families, and the community about eating that's good for the body and the planet.

 

WHAT WE'RE DOING

With each visit:

  • Lead educational demonstrations focusing on nutritious, seasonal, locally grown food
  • Show students how to prepare quick, easy snacks
  • Allow them to taste healthy recipes provided by our team

 

ALLERGIES:

THIS FORM MUST BE COMPLETEDEVEN IF YOUR CHILD HAS NO FOOD ALLERGIES


If this form is not completed your child will not be allowed to participate in our programming.

Purple Asparagus develops programs designed to help Chicago school children learn better eating habits and to make simple, healthy snacks and meals. If your child has one or more food allergies, please indicate these specific allergies where indicated below. In the event that a student with a food allergy participate in a Purple Asparagus program, Purple Asparagus will use its best efforts to refrain from bringing foodstuffs labeled as including the specific allergens. It is your childs responsibility to refrain from eating anything with unknown ingredients or ingredients known to contain any allergen and to notify an adult immediately if they eat something they believe may contain the food to which they are allergic, or if they feel as though they are having allergy-related symptoms. Purple Asparagus cannot guarantee that all of the ingredients it uses in its will not contain such allergens.

The undersigned therefore acknowledges that he or she understands the responsibilities outlined above, and further agrees to release Purple Asparagus and the School at which the child participates in a Purple Asparagus program (School) from any and all liability, and shall indemnify and hold Purple Asparagus and the School harmless, for any injuries, accidents, or other harm that may result from my childs food allergy while participating in a Purple Asparagus program. The undersigned further agrees that Purple Asparagus and the School will not be liable to them or any third party for any direct, indirect, punitive, incidental, special or consequential damages or any other damages whatsoever that may result related to your childs food allergy from their participation in a Purple Asparagus program at the School. This Release applies regardless of the legal theory of liability.

If you have any questions, please contact Purple Asparagus at 312.375.3296 or rachaelm@purpleasparagus.com.

Please select 'Minor(s)', then select the number of minors you are the guardian of that are participating in Purple Asparagus programming, and then press 'Continue'.
Minor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
Continue
First Student Name

First Name*

Last Name*
First Student Age Acknowledgment*
First Student Date of Birth*
I certify that I am 18 years of age or older
First Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
First Student Signature*
Second Student Name

First Name*

Last Name*
Second Student Date of Birth*
Second Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Third Student Name

First Name*

Last Name*
Third Student Date of Birth*
Third Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Fourth Student Name

First Name*

Last Name*
Fourth Student Date of Birth*
Fourth Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Fifth Student Name

First Name*

Last Name*
Fifth Student Date of Birth*
Fifth Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Sixth Student Name

First Name*

Last Name*
Sixth Student Date of Birth*
Sixth Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Seventh Student Name

First Name*

Last Name*
Seventh Student Date of Birth*
Seventh Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Eighth Student Name

First Name*

Last Name*
Eighth Student Date of Birth*
Eighth Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Ninth Student Name

First Name*

Last Name*
Ninth Student Date of Birth*
Ninth Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Tenth Student Name

First Name*

Last Name*
Tenth Student Date of Birth*
Tenth Student School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Student Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian Email Address

Email
We would like to communicate with you about our programming. Please check here if you would NOT like to receive our e-newsletters.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian Age Acknowledgment*
Parent or Guardian Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian School and Allergy Information

My child attends:


Name of School: *

Home Room Number:

My child is allergic to the following foods (write "none" or "n/a" if no allergies): *
Parent or Guardian Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!