TheraFriends Outdoor Playgroup Registration FALL 2022
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Email *
Child's Legal Name *
Chosen Name/Preferred Name *
Pronouns (more info: https://www.mypronouns.org/) *
Required
Child's Birthdate *
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Caregiver's Name *
Caregiver's Email Address *
Caregiver's Phone # *
Address *
Emergency Contact (other than caregiver listed) *
Group Day/Time *
Relevant medical information/developmental concerns *
Allergies *
Does your child have any needs for mobility/accessibility support or any safety concerns? *
Will you or another caregiver be accompanying your child during the group? If so, who? *Note: Anyone accompanying the registered child is not covered by the liability waiver* *
Does your child currently receive any therapy services, or has had any in the past? If so, which ones? *
Acknowledgement and Assumption of Risks: I, the undersigned, hereby acknowledge that I have been advised and fully understand that my child's participation in TheraFriends Outdoor Therapeutic Playgroup may expose them to certain hazards and risks which are beyond the control of TheraFriends. These risks include, but are not limited to, serious personal injury, death, and loss of, or damage to property, unpredictable environmental conditions/hazards including, but not limited, to lightning and unexpected extreme weather conditions, insect and animal bites and stings, heat or sun-related injuries or illnesses, and any hazards present in the wilderness such as, but not limited to, low lying branches, sharp objects, slippery surfaces, irritating/sticky bushes and plants. As a condition of their participation in this program, I agree to assume full responsibility for all the risks that such participation may entail. Their participation is entirely voluntary, and I elect for them to participate with full knowledge of the inherent risks. *
Required
Release and Indemnifications: I do hereby, in consideration of my child's participation in the Outdoor Therapeutic Playgroup, voluntarily elect to assume all risks of loss or damage to any property or any injury, including death, and hereby knowingly and freely release and agree to hold harmless and indemnify TheraFriends, its Directors and Officers, employees, volunteers, agents, collaborators, and sponsors from any and all liability, claims, demands or causes of action whatsoever by reason of any damage, loss, exposure, or injury or death arising out of my child's participation in the program and from any and all liability for any act or omission or negligence or strict liability in obtaining, rendering or failing to obtain first aid or any kind of emergency medical care. This Release and Waiver of Liability shall be fully binding on the spouse, family, heirs, executors, administrators, successors, and assigns of the participant. *
Required
I hereby authorize TheraFriends and its employees, volunteers and/or agents to administer first aid and/or emergency medical treatment and/or to secure such medical services that may be considered necessary. *
Required
Photo/Video Release: I grant permission for TheraFriends to use photographs/videos, including myself or my child for any of its promotional materials(e.g., brochures, newsletters, website, social media sites, grant proposals, news media, etc.) without payment or any other consideration. *
Required
Full legal name of participant *
Parent/Guardian Signature (typed name indicates signature) *
Date of Signature *
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A copy of your responses will be emailed to the address you provided.
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