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THIS IS A LEGAL DOCUMENT: PLEASE READ CAREFULLY BEFORE SIGNING

SUMMIT COMMUNITY GARDENS + EATS

SUMMER CAMP RELEASE AND WAIVER


As the parent/guardian of the applicant, I hereby grant permission for the below-mentioned child to participate in the Summit Community Gardens + EATS pre-K summer camp program and represent that she/he is physically able to participate in the program activities. I hereby release the Summit Community Gardens + EATS, and its employees from all claims resulting from illness, injuries, or other incidences that may be sustained by the child during attendance at the program. In the event of illness or injury, I hereby authorize the staff members of the program to obtain medical assistance or any other appropriate treatment for the below-mentioned child.

In consideration of the Summit Community Gardens + EATS services, property, and/or equipment, I enable the below-named minor child to participate in outdoor activities and hands-on learning. I agree as follows:

I UNDERSTAND that program activities involve walking through the Community Gardens, handling different plants, removing invasive species, and performing activities in the proximity of native plants, insects, and animals under the supervision of trained day garden counselors. I AGREE that the student’s participation in program activities is voluntary. I AGREE to release the Summit Community Gardens + EATS from all claims for money damages I AGREE to release the Summit Community Gardens + EATS from all unintended harm to my child resulting from the program activities. I UNDERSTAND that the Summit Community Gardens + EATS encompasses all of their officials, officers, directors, members, employees, agents, personnel, volunteers, sponsors, and affiliated organizations. I DECLARE that am a parent or legal guardian of a minor and I consent to the child’s participation and AGREE to all of the provisions and to assume all of the obligations of this Release on the child’s behalf.

BY SIGNING BELOW I forever release and discharge the Summit Community Gardens + EATS, all their employees, all their members and managers, and the staff of this program for any liability that may occur during my child’s visit. For themselves and their family, the undersigned has read and voluntarily signs the release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement have been made.

Photo Release Form for Minor Children

I hereby authorize the Summit Community Gardens + EATS to film, photograph and publish photos and footage taken of the undersigned minor children, for use on the website, social media and print materials. I release the Summit Community Gardens + EATS from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize the Summit Community Gardens to use their photographs. I acknowledge that since participation in publications and websites produced by the Summit Community Gardens + EATS is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by the Summit Community Gardens + EATS confers no rights of ownership whatsoever. I release the Summit Community Gardens + EATS, its contractors, and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.

Date: November 17, 2024


First Child's Name

First Name*

Last Name*
First Child's Date of Birth*
First Child's Information

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
First Child's Signature*
Second Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Third Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Fourth Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Fifth Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Sixth Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Seventh Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Eighth Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Ninth Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Tenth Child's Name

First Name*

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

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact & Pick-Up Authorization Form

We require at least two emergency contacts/ adults authorized for pick-up other than the parent/guardian listed on the registration form. 


Student Name: *

People AUTHORIZED to pick-up my student:


1. Name: *

Relationship: *

Phone: *

2. Name: *

Relationship: *

Phone: *
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 Information

Allergies: *

Medications: *

Medical/Cognitive/Behavioral diagnosis- *

Primary care physician name and number: *

Parent/Guardian Name *

Parent/Guardian Phone Number *
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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