Garden to Table Summer Camp 2019 Registration

Location and Date *
Student Information
Student Name *
Student Name
Birthday *
Birthday
Family & Emergency Information
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Mobile Phone *
Mobile Phone
Home Phone
Home Phone
Best Phone Number *
Best Phone Number
Medical Information
Physician Address *
Physician Address
Physician Phone *
Physician Phone
Please list any medical conditions, including any requiring maintenance/medication (diabetes, asthma, seizures, etc.)
Allergies *
Is your child allergic to any type of food or medication?
Illnesses *
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
Authorized Pick-ups and Pick-up Information
Important note: Please arrive promptly at 12:00 PM to pick up your child. Failure to do so will result in your child’s dismissal from the program.
Photo Release
I give The Edible Classroom permission to use photographs of the registrant for publicity and promotional purposes. *
Authorization
Waiver of Liability and Indemnification: I, the undersigned, parent, guardian, legal representatives, heirs,, and assigns, hereby agree to indemnify and hold harmless and hereby releases, acquits, and forever discharges The Edible Classroom, its founders, volunteers, employees, successors and assigns from any and all actions, claims, demands, coverages, costs, losses, inquiries, expenses, judgements, attorney fees, and suits at law, equity or otherwise that may arise directly or indirectly from the above named participants involvement or participation in any manner in The Edible Classroom's programming.
Date *
Date