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Please complete the 2023 NNS Agreement and Waiver if you are participating in any programs or volunteer opportunities this year! 


Nourishing the North Shore Waiver

As a participant, volunteer, or visitor to an Nourishing the North Shore property, event, or program I agree to:

  • Respect and abide by all rules and requirements. 

I Agree

Periodically, NNS staff will take photographs and/or video for the purposes of publicity and record keeping. Participants' names are never used in connection with these photos or videos without permission. 

  • I will notify NNS staff in writing if I do not grant NNS and respective subsidiaries/affiliates the permission to use my photograph and/or video. 

I Agree

Waiver of Liability
By signing below, I hereby state that I recognize injuries and illness can occur from participation in NNS programming, events and volunteering activities. I realize there is an added risk to participating during the COVID-19 outbreak. 
I, the undersigned, my heirs and assigns, hereby, waive, release, absolve, indemnify and agree to hold harmless the directors, employees and agents of Nourishing the North Shore, and the YWCA of Greater Newburyport, NNS’s fiscal sponsor at 13 Market St. Newburyport, MA, 01950, from any claim arising out of any death, injury or illness caused or sustained by participation in Nourishing the North Shore programs, etc.. Should I be taken to the hospital for emergency purposes, I hereby grant permission to the attending physician and staff to administer anesthesia, medical, X-ray, and surgical procedures as may be deemed medically necessary or advisable. I understand that every attempt will be made to contact my listed emergency contact. 
 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Emergency Contact Information

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
First Participant's Signature*
Second Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Third Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Fourth Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Fifth Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Sixth Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Seventh Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Eighth Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Ninth Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Tenth Participant's Name

First Name*

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

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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(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's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Emergency Contact Information

Name *

Relationship *

Phone Number *

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone Number

Allergies / current medications we should be made aware of:
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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