Child's Name *

First Name

Last Name

Date Options

Week 1: June 3-7

Week 2: June 10-14

Week 3: June 17-21

Week 4: June 24-28

Primary Contact Phone Number *

(###)

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Caregiver 1 Name (Primary Contact)

First Name

Last Name

Caregiver 2 Name

First Name

Last Name

Phone

(###)

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Does your child have any allergies?

Yes

No

My child has been vaccinated for:

Measles

Mumps

Rubella

Polio

Waiver Signed

I/WE HEREBY AGREE AND CONSENT TO THE FOLLOWING:

1. PARENTAL/LEGAL GUARDIAN AUTHORIZATION SIGNATURE FORM FOR MEDICAL TREATMENT In the unlikely event that a serious emergency arises it may become necessary for a physician to attend to your child before the staff can contact you. Your SIGNATURE ON THE AUTHORIZATION FOR MEDICAL TREATMENT FORM is needed to ensure that proper emergency care is provided. This authorization must be signed in order for your child to attend Nature Kin Farm & Forest School programs. I hereby authorize Nature Kin Farm & Forest School to provide first aid, including care rendered through the facilities of the nearest physician or hospital for any emergency that may arise while he/she is in attendance at school. I will assume full financial responsibility for all medical, nursing, or surgical care, including transportation of my child. I have carefully reviewed the health procedures information. The information I have provided on this enrollment form is accurate to the best of my knowledge.

First Name

Last Name

2. MEDIA CONSENT FORM AND RELEASE FOR MINOR CHILDREN I am the parent/guardian of:

First Name

Last Name

I hereby grant Forest School Teacher Institute LLC, a Tennessee limited liability company (“FSTI”) and their agents and employees the absolute right and permission to use photographic portraits, pictures, digital images or videotapes of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any FSTI publication, website, social media page, or other advertisement, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied. However, I reserve the right to request the removal of My Child’s likeness from any website, social media, or other digital reproduction from FSTI at any time and FSTI hereby agrees to honor any such request within 48 hours. I hereby release, discharge, and agree to indemnify and hold harmless FSTI and its employees and agents from all claims, demands, and causes of action that I or My Child have or may have by reason of this authorization or use of My Child’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. I represent that I am at least eighteen (18) years of age and am fully competent to sign this Release. THIS IS A RELEASE OF LEGAL RIGHTS. READ IT CAREFULLY AND MAKE SURE THAT YOU UNDERSTAND IT PRIOR TO SIGNING. SIGNING BELOW WILL SIGNIFY BINDING CONSENT WITHOUT RESERVATION ON BEHALF OF YOUR CHILD.

First Name

Last Name

Date

MM

DD

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