Live Bee Presentation Signup Form

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Saturday June 18, 2022
Session One - 1:30PM - 2:30PM (KIDS ONLY SESSION - WITH GUARDIAN)
Session Two - 3:00PM - 4:00PM (OPEN TO ALL)

Location: deKoven House Community Center - 27 Washington Street, Middletown, CT 06457

This form is required for all attending the Live Bee Presentation. A maximum of 20 people per session are allowed. Priority is awarded to those that sign up first until all the spots are filled. Completion of the form before the date of the outing is mandatory. Thank you!

A parent, guardian or responsible adult must be present for each child for the duration of the tour.

Note: Please have children wear boots or shoes covering their ankles. A bee suit will be provided for all attending.

Email *

Your Name (First, Last) *

How many people will be attending, including yourself.

Clear selection

Please list the name & age of any participants under the age of 18: A parent, guardian or responsible adult must be present for each child for the duration of the tour.

Select the Session you would like to attend. *

Session One: 1:30pm - 2:30pm

Session Two: 3:00pm - 4:00pm

Address (Number, Street, Town, Zip)

Phone Number

Emergency Contact Name* *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Are you a member of The Rockfall Foundation? *

Yes

If you, or any member of your party under the age of 18, have any medical condition(s) that could impact your ability to safely complete this outing, please provide enough information that we can support you if you have a medical challenge. e.g. you have a serious allergy and carry an Epipen. Other examples: diabetic, heart condition, a recent sprain or broken bone.

If anyone is over 6-foot 6-inches tall let us know in the short answer text below.

Acknowledgement of Outing Member Responsibility, Express Assumption of Risk, and Release of Liability *

I understand that during my and individuals registered by me under the age of 18, participation in this Rockfall Foundation Outing, I (we) may be exposed to a variety of hazards and risks, foreseen or unforeseen, which are inherent in each Outing and cannot be eliminated without destroying the unique character of the Outing. These inherent risks include, but are not limited to, the dangers of serious personal injury, property damage, exposure to COVID 19 and death (“Injuries and Damages”) from exposure to the hazards of travel and The Rockfall Foundation has not tried to contradict or minimize my (our) understanding of these risks. I (we) know that Injuries and Damages can occur by natural causes or activities of other persons, animals, trip members, trip leaders and assistants or third parties, either as a result of negligence or because of other reasons. I (we) understand that risks of such Injuries and Damages are involved in travel such as Rockfall Foundation Outings and I (we) appreciate that I(we) may have to exercise extra care for my(our) own person and for others around me (us)in the face of such hazards. I(we) further understand that on this Outing there may not be rescue or medical facilities or expertise necessary to deal with the Injuries and Damages to which I (we) may be exposed. In consideration for my (our) acceptance as a participant on this Outing, and the services and amenities to be provided by The Rockfall Foundation in connection with the Outing, I (we) confirm my understanding that: • I (we) have read any rules and conditions applicable to the Outing made available to me; I(we) will pay any costs and fees for the Outing; and I acknowledge my participation is at the discretion of the leader. • The Outing officially begins and ends at the location(s) designated by The Rockfall Foundation. The Outing does not include carpooling, transportation, or transit to and from the Outing, and I (we) am personally responsible for all risks associated with this travel. This does not apply to transportation provided by The Rockfall Foundation during the Outing. • If I (we) decide to leave early and not to complete the Outing as planned, I(we)assume all risks inherent in my (our)decision to leave and waive all liability against The Rockfall Foundation arising from that decision. Likewise, if the leader has concluded the Outing, and I decide to go forward without the leader, I(we) assume all risks inherent in my (our) decision to go forward and waive all liability against The Rockfall Foundation arising from that decision. • This Agreement is intended to be as broad and inclusive as is permitted by law. If any provision or any part of any provision of this Agreement is held to be invalid or legally unenforceable for any reason, the remainder of this Agreement shall not be affected thereby and shall remain valid and fully enforceable. • To the fullest extent allowed by law, I (we) agree to WAIVE, DISCHARGE CLAIMS, AND RELEASE FROM LIABILITY The Rockfall Foundation, its officers, directors, employees, agents, and leaders from any and all liability on account of, or in any way resulting from Injuries and Damages, even if caused by negligence of The Rockfall Foundation its officers, directors, employees, agents, and leaders, in any way connected with this Outing. I (we)further agree to HOLD HARMLESS The Rockfall Foundation, its officers, directors, employees, agents, and leaders from any claims, damages, injuries or losses caused by my own negligence while a participant on the outing. I (we) understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrators and assigns, and includes any minors accompanying me on the Outing.

I certify that I or individual registered by me under the age of 18 will not attend this Rockfall Foundation program if any of the following are true: I or any individual in my household have tested positive for COVID-19; or has experienced symptoms of COVID-19 in the preceding 14 days, including but not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose. I or a member of my household has recently had close contact with a person infected with COVID-19 or I have attended large gathering of people. *

Check Box

Required

I understand that to participate in this Rockfall Foundation program that I and all members of my party must wear a face mask in the following situations: when I (we) arrive, when requested by the event leader and any time I (we) am closer than 8 feet from another person. I (we) also understand that even when I (we)am wearing a mask, that I (we) need to try to maintain at least a 6 feet distance between myself (ourselves)and anyone that is not part of my household. *

Check Box

Required

I (we) agree to notify Tony Marino at The Rockfall Foundation (tmarino@rockfallfoundation.org) if I (we) test positive for COVID-19 or have reason to believe that I (we) had COVID-19 within 14 days after attending this program. *

Check Box

Required

I hereby authorize The Rockfall Foundation and their supporters to use my likeness and those registered by me for promotion of The Rockfall Foundation's mission to connect people with nature. I understand that such promotion may be disseminated through printed materials and/or electronic avenues. If you do not wish The Rockfall Foundation to use any photograph in which your face can be seen, please write a note in the comments section below.

Check Box

I have read this document in its entirety and I freely and voluntarily assume all risks of such Injuries and Damages, as detailed above, and notwithstanding such risks, I agree to participate in the Outing. *

Check Box

Required

Signature (type name) *

Date *

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