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EXCURSION/FIELD TRIP WAIVER AND MEDICAL AUTHORIZATION

Date: June 15, 2021

I fully understand that my child is to accept all rules and requirements governing conduct during the field trip.  It is understood that any child determined to be in violation, or unfulfilling of this behavior standard will be sent home at the parents' or guardians' expense.  Parent or guardian has to be ready to pick up the child anytime during the field trip.

I, the undersigned, hereby release and discharge Bionerds, its members and employees (herein collectively referred to as "Company") from all liability arising out of or in connection with the described field trip or excursion.  For the purposes of this agreement, liability means all claims, demands, losses, causes of action, suits, or judgments of any and every kind that I, my heirs, executors, administrators or assignees may have against the Company because of any death, personal injury or illness, or because of any loss or damage to property that occurs during the described field trip or excursion and that results from any cause other than the negligence of the Company.

In the event of any illness or injury, I hereby consent to whatever X-ray, examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child.  It is understood that the resulting expenses will be the responsibility of the parent(s) or guardian(s) or participant.

Coronavirus (COVID-19) related safety

I understand parents/guardians and participants must adhere to all safety and behavior guidelines implemented by the state of California and/or local government/agencies regarding COVID-19 to ensure both students and teachers safety, such as wearing masks, social distancing guidelines, and more.  Parents or guardians are responsible to notify Bionerds if at least one of the questions below regarding your child's overall health has changed DAILY. Do NOT bring your child to our program if your child is experiencing any COVID-19 symptoms or feel sick in general before the day of our program.  If your child is experiencing any general sickness or COVID-19 symptoms in class, a parent or guardian must pick up the child immediately from the classroom.  Refer to the Centers for Disease Control and Prevention (CDC) website for more information about COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/index.html).

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
First Participant's Signature*
Second Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Third Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Fourth Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Fifth Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Sixth Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Seventh Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Eighth Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Ninth Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Tenth Participant's Name

First Name*

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

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*

If Other Field Trip chosen above, please describe: *
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
Participant's 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's Email Address

Email*

Confirm Email*
Check to receive Bionerds class updates and our newsletter e-mail.
Parent or Guardian's Information

Parent/Guardian's Full Name: *

Relationship to child: *

Phone Number: *

Address (Street, City, Zip Code): *
Emergency Contact

Name: *

Relationship to child: *

Phone number: *

Email address: *
Questions
I have read the Bionerds Sexual Abuse and Misconduct Prevention Policy and understood the content: (https://www.bionerdsllc.com/index.php/samp-policy/) *
Yes
I have read the Bionerds Participant Conduct and agreed to review it with my child: https://www.bionerdsllc.com/index.php/participant-code-of-conduct/ *
Yes
How did you hear about us?*

If Other, please elaborate (type N/A if already chose an option above): *
Health Insurance Information

Health Insurance Company: *

Policy Number: *

Insurance Company Address: *
SPECIAL NOTE TO PARENTS/GUARDIANS:

  • We do not administer drug or medication to your child.
  • We do not provide transportation to and from the field trip site.  The parent or guardian will drop off the child NOT earlier than 10 minutes before the scheduled time, and pick up the child by the scheduled time.  We do not provide day care afterward.


    List any allergy if any:

    • For some field trips, parents are welcome to join us. Some field trip or excursion site has limited number of parent/chaperon allowed or none recommended at all.  Parents and guardians may have to pay extra fee for their own expenses or admission tickets.


    Initial here: if there are NO special issue(s) or concern(s) that the staff should be aware of regarding your child.

    • If your child has a special medical problem, kindly write below or attach a description of that problem to this sheet.  We will try our best to give special accommodation but no guarantee.

    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*

    Relationship*
    Parent or Guardian's Date of Birth*
    I certify that I am 18 years of age or older
    Parent or Guardian's Information

    I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

    Field trip:*

    If Other Field Trip chosen above, please describe: *
    I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*
    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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