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Waiver and release for each participating girl and chaperone.

PHOTOGRAPH RELEASE FORM - By signing the photographic release below, you are agreeing to allow photographs of yourself, and minors accompanying you, to be used by the Loxahatchee River District (LRD), and the River Center. If your picture has been taken in reference to a particular program, your name will be used in connection with the photograph(s) and may be associated with your name/your company’s name/your organization’s name.

I GIVE MY PERMISSION, without restriction, for consideration received, for the above mentioned agencies (LRD, River Center) to take, reproduce and publish, in all media including electronic formats known or unknown, photographs of me, or to have this done on its behalf. I understand that these photographs may be used, in whole or in part, in informational, educational or commercial publications of any kind (including without limitation, electronic publishing), by the Loxahatchee River District and its agents.

I UNDERSTAND AND AGREE THAT:

  • I will not have any right to inspect the finished work or product or to approve its use.
  • Ownership of the originals and all copies belongs to LRD and its agents. This includes all rights to use, not use, or dispose of the photographs, in any manner whatsoever.
  • The agreements in this Release are legally binding and cannot be changed by me or someone who has been given my rights.

Initial:

 

Assumption of the Risk and Waiver of Liability

Relating to Coronavirus/COVID-19

 

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

 

The Loxahatchee River Environmental Control District, operating the “River Center” (herein the “District”) has put in place protective measures to reduce the spread of COVID-19; however, the District cannot guarantee that you, the participant, or your child(ren), if applicable, will not become infected with COVID-19. Further, attending activities on and off the facilities of the District could increase the participant(s) risk of contracting COVID-19.

 

By signing this agreement, I, the undersigned, acknowledge the contagious nature of COVID-19 and on behalf of myself, my child(ren), my spouse/co-parent of child(ren) voluntarily assume the risk that I, my child(ren), and any member of my family, may be exposed to or infected by COVID-19 by attending activities on and off the facilities of the District and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 while on and off the facilities of the District may result from the actions, omissions, or negligence of myself and others, including, but not limited to, District employees, agents and representatives, volunteers, program participants and their families and/or any other individual who may be on and off the facilities of the District or in attendance at any District activity.

I voluntary agree to assume, on behalf of myself, my child(ren), and my spouse/co-parent of child(ren) all risks and accept sole responsibility for any injury to myself, my child(ren) and any member of my family, (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I, my child(ren) and/or members of my family may experience or incur in connection with attendance in activities or participation in the District programming (“Claims”).

On my behalf, and on behalf of my child(ren) and/or members of my family, I will advance no claim and I hereby release, covenant not to sue, discharge, defend, indemnify and hold harmless the District, its employees, agents and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that thus release includes any Claims based on the actions, omissions, or negligence of the District, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any District activity.

Additionally, it should be noted that the laws of the State of Florida provide for numerous immunities for governments should something occur to a participant or to the family of a participants as a result of activities on and off the government property. In addition to this Agreement, these immunities remain intact.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to all parties, we are conducting a simple screening questionnaire with this waiver. Your participation is important to help us take precautionary measures to protect you, your Child(ren) and everyone on campus. 

Date of Signing: November 30, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
rivercenter@lrecd.org
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Event Details

Date of the Girl Scout Event you are attending: *
Name of the Event*
COVID Questions
Have you, your child(ren), or anyone in your immediate family had close contact with or been diagnosed with COVID-19 within the last 30 days?*
No
Yes
Have you, your child(ren), or anyone in your immediate family experienced any of the symptoms below in the last 14 days? (Fever, cough, chills, sore throat, respiratory illness, difficulty breathing, or loss of taste and smell)*
No
Yes
NOTIFICATION - If I, my child(ren), or any of my immediate family members develop any of the above symptoms I will keep them home, notify the District's Education Manager and seek medical care to obtain a physician's note stating it is safe to return to participation.*
No
Yes
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's 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.


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