21 Acres Activity Release Form

This field is for validation purposes and should be left unchanged.

Please enter the name of your group, organization, or class.

Enter or select a date.

Please choose only one activity.

By checking this box I acknowledge that injuries and accidents may occur during my activities or the activities of a minor I am responsible for at 21 Acres. I release and discharge, and hold harmless and indemnify, 21 Acres and its directors, officers, employees, and volunteers from any and all claims, damages, losses and lawsuits, including attorney fees, by or to myself or any minors for whom I am responsible, regardless of any party’s negligence or lack thereof, arising out of my activities or the acts or omissions of any minors for whom I am responsible.

Further, I give permission for representatives of 21 Acres to provide or arrange emergency medical care for me or any minors for whom I am responsible, and to arrange for transport to an emergency center for treatment. I consent to medical treatment deemed immediately necessary or advisable by a physician if I am unable to act on my own behalf. I further understand that 21 Acres is not responsible for payment for such medical treatment. If I or a minor for whom I am responsible is injured, I will notify 21 Acres personnel and fill out an accident/injury report.

I agree that 21 Acres is not responsible for personal property lost, damaged or stolen while participating in activities with or at 21 Acres.

I agree to follow Center of Disease Control (CDC), local health district guidelines, and 21 Acres policies and procedures for social distancing, masking, sanitation, and vaccination requirements as outlined by King County to reduce the spread of Novel Coronavirus, or COVID-19.

I understand that there is no direct medical health coverage afforded to me during my relationship with 21 Acres. 21 Acres is not responsible for any potential exposure to Novel Coronavirus, or COVID-19, which is not a direct result of negligence on the part of their employees, volunteers, or the organization. Unless specifically stated in writing, I understand that there is no Washington State Labor and Industries employment security insurance provided to me.

As a health and safety measure, and in alignment with guidance from the Governor’s office and King County health officials, 21 Acres will participate in contact tracing to allow for notification if a volunteer may have been potentially exposed to COVID-19. Volunteer contact information will be retained for this purpose. The information will only be shared with public health officials if you are exposed and health officials will then contact you to explain the risk, answer your questions, and provide resources.

By checking this box, I agree to comply with the written instructions provided to me in the 21 Acres COVID-19 Volunteer Policy. Failure to comply with these written instructions or verbal instructions from staff may result in my volunteer privileges being removed and I may be asked to leave the premises.

By signing I grant 21 Acres the right to use photographs, video or voice recordings, or likeness of me or minors for whom I am responsible, without the participant’s name, for publicity and educational purposes by 21 Acres. I understand that all materials will remain the property of 21 Acres and I am not entitled to any compensation or payment for their use.

This field is for validation purposes and should be left unchanged.

21 Acres Activity Release Form

21 Acres Activity Release Form

Participant Information

Emergency Information

Guardian/Parent Information

21 Acres Center