Test – West Maple Farm

Boys-after-school-farming-program test

Childs Name Age Grade Yeshiva / School We understand that each child is different and has different needs. Please let us know if your child may need any extra help or attention. Reference Name Relationship to Child Reference Phone Number Address City State Zip Code Mothers Cell Phone Fathers Cell Phone Email Person Authorized for drop-off & Pickup Emergency Contact Name Emergency Contact Phone

In the event of an emergency, contact:

Childs Pediatrician Pediatrician Phone Allergies / Special Needs Is your child allergic to Bee Stings? If yes please make sure they have an EpiPen With them daily. Yes No

Medical Emergency Consent Plan

In the event that emergency medical aid/treatment is required due to illness or injury during activities, or while on the property of the agency, I authorize West Maple Farm to:
1. Secure and maintain medical treatment and transportation as needed.
2. Release participant records upon request to the authorized individual or agency involved in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed necessary or “life saving” by the physician.

Rockland Agricultural & Farming Center Liability Release and Agreement for this Facility and Program

I hereby:

1. Hold West Maple Farm / Rockland Agricultural & Farming Center (RAAFC) ; its owners, employees, agents, and/or volunteers harmless for any and all injuries or illness incurred by myself, my minor children and any others that accompany me on said property. I shall bring no claims, demands, actions, causes of action and/or litigation against West Maple Farm and/or its associates or owners for any loss due to bodily injury or death sustained by me, my minor children, legal ward, in relation to the premises and operation of this facility, which includes handling, or being near animals.

2. Acknowledge and fully understand that I will be engaged in an activity that might result in serious injury including permanent disability or death, and severe social and economic loss. Not only by my action, inaction, or negligence, but also by the action, inaction and negligence of others, the rules of the sport/activity, or conditions of the premises or equipment used. Further, I acknowledge that there may be other risks not known to me or foreseeable at this time.

3. Understand that no pets other than the animals of West Maple Farm ( RAAFC) will be allowed on the property.

4. Understand and agree that anyone using this facility and/or parent/guardian will repair or reimburse West Maple Farm ( RAAFC) for all expenses which include materials and time in the event of any damage to equipment on the property.

5. Understand that West Maple Farm ( RAAFC) has permission to take and post any photos taken of my child during camp hours to their website & advertisements.

6. If my child is allergic to bees It will be my responsibility to make sure they have an EpiPen With them daily.

I have read this and understand that by submitting this form , and knowing this I sign it freely and voluntarily agree to participate and/or have my minor children participate, knowing conditions involved and do so of my own free will.

I agree to all above. AgreeSignature

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Registration & Payment

Fee is $350 per child.

Once you successfully submit this form and we accept your child, we will charge you the full amount.

All payments are non- refundable.
The name on your credit card statement will show as Rockland Farming & Agricultural Center

A confirmation email will be sent to upon receipt of completed registration and payment.

Boys after School Farming Program Price: $350.00

As the credit card holder, I authorized the services being performed by West Maple Farm and I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in the signed program application.

Signature

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