Circle Of Parents Registration

First Name

Last Name

Home Phone Number

Email Address

Zip Code

Gender Identity

Racial Identity

Are you of Hispanic, Spanish, or Latino Origin?

Sexual Orientation

Marital Status

Primary Language

Do you have any food allergies? (Select all that apply)

Do you need any accommodations for vision, hearing, or mobility to participate in the class?

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

Gender Identity

Of Hispanic, Latino, or Spanish Origin?

Racial Identity

Does this child have any food allergies? (Select all that apply)

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 electronic 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, 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 activities at Mountain Resource Center.

I will follow general CDC and the State of CO health guidelines by:

-Not attending class if I am currently experiencing symptoms of COVID-19 including but limited to coughing, congestion, loss of taste and smell, or fever.

- Not attending class if I have tested positive for COVID-19. If positive for COVID-19, I understand that I cannot come to class until 5 days have passed and I am symptom free. I also understand that I may return to class after the 5-day mark if symptom free, but I will need to wear a mask during the class until day 10.

These requirements may change at any time to comply with local and national guidelines.

I ACCEPT

Electronic Signature

Contact Information

Group Member	Family/Friend	Social Media
Brochure/Flyer/Website	Social Worker	Legal/Judicial
Community Agency/Non-Profit	Faith Community	Health Provider
Mass Media	Other