Earth Warriors Registration

Child's Name *

First

Last

Date of Birth *

Registering for the following camps: *

Little Bluebirds Preschool
Earth Warriors Nature Club

Parent or Guardian's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Secondary Phone Number

Email *

Emergency Contact's Name *

First

Last

Emergency Contact's Phone Number *

Please share your child's strengths/passions:

Any physical and/or dietary restrictions?

Allergies (please specify):

Medications:

Any other physical, social, or emotional challenges we should be aware of:

RELEASE, INDEMNIFICATION AND WAIVER FORM: (This is a release – please read it carefully.) *

I, the undersigned, hereby acknowledge that I have been advised and fully understand that certain elements of danger are inherent in the activities sponsored by Bluebird Hill Homestead which are beyond the control of the instructors, agents, officers, students, and employees of Bluebird Hill Homestead, and that participation in any program activities may entail unavoidable risk of personal injury, death, and loss of or damage to property. These risks include, but are not limited to insect and animal bites and stings, forces of nature such as but not limited to lightning, and unexpected extreme weather conditions, and any hazard present in the wilderness, such as but not limited to low lying branches, sharp objects, and slippery surfaces. I hereby assume all risks of injury and death to the participant and loss of or damage to property arising out of participation in such activity and I agree to indemnify, hold harmless Bluebird Hill Homestead, its officers, instructors, agents, and employees (“Releasees”) from and against all claims arising from any occurrence causing damage or injury to myself or to any party participating in said event or any third parties injured as a result of my actions. I further agree to repair or reimburse Bluebird Hill Homestead for any and all damages that I cause to Bluebird Hill Homestead property or the property at which a specific activity is held. Prior to signing below, I have read and understand the terms and conditions of this Release, Indemnification, and Waiver, understand by signing below I am waiving certain legal rights I may have against the Releasees, and I agree to subscribe to all the terms and conditions set out above.

PHOTO/VIDEO RELEASE:

By checking this box, I hereby grant free permission for Bluebird Hill Homestead to use still or motion picture images of the person participating in their programs or events for outreach purposes, including but not limited to electronic or print materials, or print or broadcast media. (Please consider granting this release if at all possible, as this helps us greatly with sharing about our programs. We do not share names of participants publicly.)

ELECTRONIC SIGNATURE *

By checking this box, I acknowledge that typing my name below constitutes my online signature and is as legally binding as such.

Please type your name as your signature: *

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