WiseTies CoGardens | Westwood-IndianHills & Neighboring Developments

"WIND Sows. Family Grows."

Family Growing Nickname

example: The Putmans Play Dirty

Parent/Guardian Information

Name

First Name: Last Name:

Address

Street Address Street Address Line 2 City State/province Postal/Zip Code Country

Home Number

Cell Number

E-mail

Parent/Guardian Information

Name

First Last

Cell Number

Email

Child's Information

Child's Name

First Name: Last Name:

Birth Date

Gender

Male
Female

Grade

Child's school

Child's Information

Child's Name

First Name: Last Name:

Birth Date

Gender

Male
Female

Grade

Child's School

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Alt. Phone Number

Would the parents be able to access the online sessions Tuesdays/ Thursdays 11:00 am until 12:00 pm? If not, please describe how we can help you attend.

Are there any allergies from seedlings that WIND,CDC needs to be aware of? If yes, please list the participating person and their allergy.

Informed Consent and Acknowledgement*

I hereby give my approval for my family participation in any and all activities prepared by WIND,CDC during this growing initiative. In exchange for the acceptance of said family's candidacy by WIND,CDC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless WIND,CDC and all its respective officers, agents, and representatives from any and all liability for injuries to said family arising out of traveling to, participating in, or returning from WiseTies CoGardens sessions. In case of injury to said family member, I hereby waive all claims against WIND,CDC including all farmers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all growing activities, including picking, chopping and storing. Some of these injuries include, but are not limited to, the risk of cuts, scrapes, slips, falls, fractures, paralysis, or death.

Medical Release and Authorization*

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the WIND,CDC and its affiliates including off duty medical personnel, Certified First Aid Responders, to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the WiseTies CoGardens sessions. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation*

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.