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21 Acres Activity Release Form
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Click to download PDF printable form
21 Acres Activity Release Form
In order to participate in the activities held at 21 Acres, this document must be completed and signed by the participant. If the participant is less than 18 years old, a parent/guardian must agree to the terms and complete the form on their behalf. Your information is for 21 Acres use only and will not be shared with any other organization.
Group Name
*
Please enter the name of your school, group, or class.
Date of Visit to 21 Acres
*
Enter or select a date.
Date Format: MM slash DD slash YYYY
Activity Type
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Please choose only one activity.
Field Trip (schools and groups ages Pre-K through college)
Summer Camp (only for 21 Acres Summer Camps, pre-registered)
Tour (usually private groups with adults)
Class Participant (21 Acres sponsored classes)
Community Partner (other 21 Acres community members who are partnering with us in other ways)
Release from Liability
*
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.
I agree to the release from liability.
Medical Treatment
*
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 to the medical treatment policy.
Property Loss
*
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 the property loss policy.
Media Release
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.
I agree to the media release
Emergency Information
Your emergency contact should be someone who is not on campus with you during the day of your visit. This information will only be used in the event of an emergency.
Emergency Contact Name
*
First
Last
Emergency Contact Phone Number
*
Participant Information
Participant Name
*
First
Last
Participant Age
*
17 or under
18 or over
Participant Phone
*
Participant Email
*
Participant Optout
We love to let our community know about upcoming classes, fresh food, and fun events. Check this box to hear about what's new on campus. (Recommended)
Participant Signature
*
Guardian/Parent Information
Required if participant is under the age of 18
Guardian Name
*
First
Last
Guardian Phone
*
Guardian Email
*
Guardian Optout
We love to let our community know about upcoming classes, fresh food, and fun events. Check this box to hear about what's new on campus. (Recommended)
Email
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