Spring Farm and Forest 2019 Registration
Health Statement, Indemnity, Release & Assumption of Risk
Farm & Forest Cubs is a 10 week program that runs from 9:30am to 12:30pm. When registering you can select to attend one session per week, two sessions per week or three sessions per week.
Participant Allergies/Special Needs (including social, emotional, behavioral, and/or physical needs)
Emergency Contact Information
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent/Guardian 1 Mobile
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Mobile
Primary Family E-mail
Secondary Family E-mail
Mailing Zip/Postal Code
Every box but the photo release must be checked in order to participate in the Farm and Forest Program. If you have any questions please call the Calleva office 301-216-1248
I acknowledge and agree that myself or my child is participating in a Calleva program. I fully understand and agree that there is the possibility of an accident or other physical injury and agree to assume the risk of such injury and further agree that Calleva, Inc., shall have no responsibility or liability in the event that I or the minor child for whom I am responsible suffer(s) any injury or harm.
I declare that (I am)/ (the minor child for whom I am responsible is) in good physical health and believe that is able without reservations or limited conditions to physically withstand and cope with the indicated rigors of this program.
If I am an adult Particpant or the Parent of a minor Student I agree, for myself and on behalf of the minor student for whom I sign as follows: I understand and acknowledge that the description above the inherent risks of Calleva's activities is not complete and that other, including unknown or unanticipated, risks, inherent and otherwise, may result in property loss, injury, illness or death. I acknowledge that my participation in this Calleva experience is purely voluntary, and I wish to participate in spite of and with knowledge of the inherent and other risks involved. I acknowledge and assume the inherent risks described above and all other inherent risks of my Calleva activity. In addition, except for an injury or other loss which occurs on lands whose rules or regulations prohibit my doing so as a matter of law, I expressly assume ALL risks of my Calleva activity, inherent or otherwise, and whether or not described above.
(AGREEMENT OF RELEASE AND INDEMNITY: On behalf of myself and any minor child for whom I sign, I hereby release and hold harmless Calleva and its owners, directors, officers, employees, contractors and other agents (each a “Released Party”) from all liabilities, injuries, damage, causes of action, complaints, suits, claims, obligations, costs, losses and all other legal responsibilities (collectively, “Claims”) suffered by me or such minor child and arising from participation in any activity of Calleva unless such Claim is caused by the gross negligence, malice or willful misconduct of the Released Party against whom the Claim is brought. I specifically agree not to institute or cooperate with any Claim in violation of the foregoing sentence. I further agree to indemnify and defend Calleva or any other Released Party against any Claim that may be brought against it by any person if such Claim is attributable to any of my or my minor child’s actions or failure to act, is such actions or failure to act constituted gross negligence, malice or willful misconduct on the party of my child or me. THE PARTICIPANT HAS READ THIS PAGE AND UNDERSTANDS AND VOLUNTARILY AGREES TO ITS TERMS, WHICH SHALL BE BINDING UPON THEM, THEIR HEIRS, ESTATE, EXECUTORS AND ADMINISTRATORS.
We hereby allow Calleva to use photographs or images of me/my child for appropriate promotional material related to the activity the participant will be enrolled in.
Program Date Option
1 Session/Week for 10 Weeks
2 Sessions/Week for 10 Weeks
3 Sessions/Week for 10 Weeks
Participant/Responsible Adult Electronic Signature
Date of Electronic Signature
Need assistance with this form?