| Participant's Name: | Parent(s) Name(s): |
| Address: | Date of Birth |
| Age | Gender |
| Phone h/w | Email: |
List any
medical conditions such as allergies, asthma, reactions to bee stings, reactions
to medicine:
Please list family
(child's) physician and phone number:
PROGRAM (Enter Date): ________________________________
FEE: No fee, donations are accepted
WAIVER: In order to participate in said program, as parent or guardian of the said participant, I assume the risk of any and all injuries to participant by the participant. I hereby agree to indemnify and hold harmless the educators, volunteers, and directors of SEEDS and Odiero, Ltd. from any and all claims for any and all injuries suffered or caused by said participant due to participation in the activities of this program.
It is likewise assumed that said participant will wear the proper clothing and protective equipment during said program (see list below) and that it is the responsibility of the parent or guardian to make sure this criteria is met. I grant my permission to transport said participant to and from said event when required and hold harmless those assigned to transport. I also agree to allow transportation of said participant to the nearest physician or hospital for medical treatment and agree to allow for immediate first aid to the injured said participant when deemed necessary.
Participant and/or Parent or Guardian has read and understands the following two statements:
YOU AND/OR YOUR CHILD WILL BE INVOLVED WITH SUPERVISED PHYSICAL ACTIVITY and may run, jump, swing, and climb trees. If you do not want your child doing certain kinds of activities, please inform us in writing and we will ask your child to refrain from said activity.
YOU AND/OR YOUR CHILD MAY COME INTO CONTACT WITH OTHER LIVING CREATURES. Bee stings, scratches from plants, and rashes as a result of contact with plants are possible. We will teach your child to identify plants like poison ivy, but they still might touch it!
IF THIS PROGRAM HAS A FEE, A DEPOSIT OF 50% is required with registration. Mail to: SEEDS PO Box 824 Blacksburg VA
24063
(Balance due on the first day of each program that you register
for.)
* If you are interested in FINANCIAL AID, please contact SEEDS.
*
If you are interested in making a donation to the SEEDS scholarship fund please
contact SEEDS. You will be helping somebody to participate who couldn't
otherwise! Your donations are tax deductible under Section 501(c)(3) of the
Internal Revenue Code.
* If you or somebody you know has a child who would enjoy the field camps and needs financial aid, please contact SEEDS.
Participant or Parent or Guardian Name (print):__________________________________________
Participant or Parent or Guardiean SIGNATURE:__________________________________________
Date:_________________