Circle Of Parents Registration
First Name
Last Name
Home Phone Number
Email Address
Zip Code
How did you learn about this Circle of Parents Group?
Please select...
Group Member
Family/Friend
Social Media/Internet
Social Worker
Court/Probation
Community Organization
Other
Gender Identity
Please select...
Female
Male
Gender Non-conforming
Prefer Not to Say
Racial Identity
Please select...
American Indian or Alaska Native
Asian
Black / African American
Hawaiian Native / Pacific Islander
Multiracial
White
Other
Prefer Not To Say
Are you of Hispanic, Spanish, or Latino Origin?
Please select...
Yes
No
Don't Know/Prefer not to Answer
Sexual Orientation
Please select...
Asexual
Bisexual
Heterosexual or Straight
Homosexual, Gay, or Lesbian
Not sure Questioning
Pansexual
Queer
Prefer Not To Answer
Other
Marital Status
Please select...
Single
Married
Partnered
Separated
Divorced
Widowed
Prefer Not to Answer
Other
Primary Language
Please select...
English
Spanish
Prefer Not to Answer
Other
Do you have any food allergies? (Select all that apply)
Please select...
None
Milk
Eggs
Fish (e.g., bass, flounder, cod)
Crustacean shellfish (e.g., crab, lobster, shrimp)
Tree nuts (e.g., almonds, walnuts, pecans)
Peanuts
Wheat
Soybeans
Do you need any accommodations for vision, hearing, or mobility to participate in the class?
Please select...
Yes
No
Total number of children currently in your care
0-2 years old
3-5 years old
6-12 years old
13-18 years old
Total number of children
ever in your care
( current and previous)
Participating Child(ren)
First Name of Participating Child
Last Name of Participating Child
Child's Birthdate
Child's relationship with participating adult
Please select...
Child
Grandchild
Ward
Foster Child
Family
Friend
Other
Does this child have any food allergies? (Select all that apply)
Please select...
None
Milk
Eggs
Fish (e.g., bass, flounder, cod)
Crustacean shellfish (e.g., crab, lobster, shrimp)
Tree nuts (e.g., almonds, walnuts, pecans)
Peanuts
Wheat
Soybeans
Waivers and Covid-19 Information
By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of these Agreements. You further agree that your signature on this document is as valid as if you signed the document in writing.
Media Release
I consent to and allow Mountain Resource Center to use and reproduce any and all photographs or videotapes taken of me during my participation in Family Education Programs. I understand that Mountain Resource Center will own the photographs and video and the right to use or reproduce such photographs and videos in any media, and the right to edit them or prepare derivative works for purposes of promotion, advertising and public relations. I hereby consent to Mountain Resource Center’s use of my name, likeness or voice, and I agree that such use will not result in any liability to these parties for payment to any person or organization including myself.
I ACCEPT
Liability Waiver
I understand the risks, hazards, and dangers inherent in carrying out normal day-to-day activities while participating in Family Education Programs. I agree for myself and my heirs, to release and hold harmless, defend and indemnify the Mountain Resource Center and Illuminate Colorado, its trustees, officers, agents, employees, and volunteers, from and against all claims, demands, actions, and causes of action as a result of personal injury, death, or property damage sustained by me or by others due to this activity.
I ACCEPT
Covid-19 Waiver and Guidelines
I understand and assume the risk that, despite MRC’s best efforts to prevent spread of the illness, I may become ill from COVID-19 and such illness may result in serious illness, up to and including death. I hereby assume the risk of bodily injury, illness, death, medical treatment, and property damage resulting from attending Circle Of Parents. I hereby release, discharge and agree to indemnify and hold the Mountain Resource Center harmless from, and waive on behalf of myself and my heirs and personal representatives and any minors I am responsible for who attend with me, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Mountain Resource Center, or that may otherwise arise in any way in connection with any voluntary activities with, or for Mountain Resource Center.
I will follow general CDC and the State of CO health guidelines by:
-Having not traveled internationally in the past 14 days or to a highly-impacted area within the United States in the past 14 days before attending Culinary Adventures.
- To the best of my knowledge, I have not been exposed to a person with a confirmed or suspected case of COVID-19 within fourteen days of attending Culinary Adventures.
- I have not been diagnosed with COVID-19; or, I have been diagnosed with COVID-19 and I have been symptom free without the aid of any medications for more than 72 hours.
- I understand that my temperature may be taken by someone from MRC before Culinary Adventures begin.
-I will follow recommended CDC and state guidelines - practicing social distancing by participating in group activities of fewer than 10 people, trying to maintain separation of six feet from others, and otherwise limiting my exposure to the coronavirus.
-I will wear a mask or face covering while participating in any activity.
I ACCEPT
Electronic Signature
Contact Information