Summer Camp | Center for Urban Agriculture at Fairview Gardens

Parent / Guardian Information

Parent/Guardians Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Child's Information

Child's Name*

First Last

Child's Age*

If your child has any allergies or dietary restrictions, please list them below.*

Is there anyone else authorized to pick-up or drop-off your child (Friend, Nanny, other Parent)?

yes
no

Authorized persons name

Has your child attended a program at the farm in the past?*

Yes
No

Is there anything else you would like to share about your child?

Waivers and Liability Information

Insurance Company

Policy/Group Number

Local Emergency Contact

Emergency Contact Number

Relation to Child

Video & Photo Release

I hereby authorize The Center for Urban Agriculture at Fairview Gardens (CUAFG) and those acting pursuant to its authority to photograph, video tape, or use any other electronic method of recording my likeness and/or voice to be used at CUAFG’s discretion in Fairview Gardens publications and/or web sites. The photographs and/or video footage will not be digitally manipulated to change its content.

I hereby give CUAFG the absolute right and permission, without restrictions, to make, copyright, and/or use, re-use, or publish said photographs/video footage of me in which I may be included in whole or in part, and waive any right to inspect and/or approve the finished printed materials, videos and/or web sites where my image appears. I further consent that my name and identity may be revealed therein or by descriptive text or commentary.

I release CUAFG and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of CUAFG.

I waive any right to compensation for my appearance in these printed documents, videos or web sites in any and all future uses of the photographs and/or video footage.

I consent to the Video & Photo Release Above*

Yes
No

Medical and Liability Release*

I agree to the Medical and Liability Release.

In consideration for being accepted by FAIRVIEW GARDEN/THE CENTER FOR URBAN AGRICULTURE to participate in the below described program, we (I) [and on behalf of our (my) child-participant] do hereby release, forever discharge and agree to hold harmless FAIRVIEW GARDEN/THE CENTER FOR URBAN AGRICULTURE and the staff thereof from any and all liability, claims or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the Fairview Gardens Youth Programs.

Furthermore, we (I) [and on behalf of our (my) child-participant] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation, including tree climbing, and/or work activities involved therein. I authorize the staff of Fairview Gardens to act for me according to their best judgment in any emergency requiring medical attention. I understand that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover such charges and fees. I further understand that I am required to maintain and carry accident insurance coverage for the child listed on this application, and verify that the coverage information that I have provided is accurate and true. I have no knowledge of any physical impairment that would be affected by the above named camper’s participation in the camp program as outlined in the brochure. I also understand that the Fairview Garden program's retains the right to use for publicity and advertising purposes, photographs of children taken at the farm. Further, authorization and permission is hereby given to said program to furnish any necessary transportation, food and lodging for this participant.

The undersigned further hereby agree to hold harmless and indemnify said FAIRVIEW GARDEN FARM/THE CENTER FOR URBAN AGRICULTURE, its administrators, employees, for any liability sustained by any other participant as the result of the negligent, willful or intentional acts of this participant, including expenses incurred attendant hereto.

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in said program.

Refund Policy*

I agree to these policies.

CAMP REFUND POLICY

Due to the increased costs of camp as a result of COVID-19 precautions, we cannot offer a refund should camp be canceled due to a high risk exposure resulting in the closure of camp. Additionally, if a child becomes ill, or someone in the immediate family is showing symptoms of COVID-19 and the risk is deemed too great for the child's return to camp, we cannot offer a refund. A credit for the balance of the camp days unused can be maintained for up to one year for future programs. We thank you for your understanding in this matter.
A refund will be issued if requested 30 days prior to the first day of the camp, less a $35 administrative fee. If less than 30 days prior to the first day of camp, no refunds will be issued. Camp is rain or shine.

Week 7: August 17-21

Week 8: August 24-28

Financial Assistance Fund! (Enter an amount below.)

If you would like to help us offer our programs to more families who might need financial assistance, please consider adding on an amount here.

Promo Code

Total

$0.00

Total cost for Spring Break Camp.

Credit Card*

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Card Number Expiration Date Security Code Cardholder Name

Parent/Guardian Signature*

I agree to the above terms and conditions.

SUmmer Camp Registration

Parent / Guardian Information

Child's Information

Waivers and Liability Information

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