Family Information Form

The following form is used to gather important information for our summer camps. It must be filled out each year you register for camps.

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Guardian / Parent

Parent Name *

Email *

Phone *

Relationship? *

Authorized Pick-Ups

Please list names and phone numbers of anyone permitted to pick up the camper

Camper Information

Full Name *

Age *

BC Health Care #

Camper Important Details

Please include allergies, medical issues, and anything else you think we should know

Emergency Contact

Name *

Phone *

Relation to Camper *

Waiver

1. ASSUMPTION OF RISKS. I am aware that participation in activities, events or services provided,
   arranged or organized by the Grist Mill and Gardens Historic Site (“Activities”) involves inherent risks, dangers and hazards, including potential property damage and personal injury. I hereby irrevocably and unconditionally accept and assume, on behalf of myself and the Minor, all such risks, dangers and hazards, including property damage and personal injury, in connection with the participation of the Minor(s) in the Activities. I confirm that I have disclosed all relevant information about the allergies and medical conditions of the Minor(s) to the Grist Mill and Gardens Historic Site.
2. RELEASE OF LIABILITY. I hereby, irrevocably and unconditionally release and forever discharge, on behalf of myself and the Minor(s), Grist Mill and Gardens Historic Site and its directors, officers, employees, agents, volunteers, independent contractors, representatives, successors and assigns (collectively, “the Grist Mill”) from any and all actions, causes of action, claims, demands, obligations, liabilities, losses, expenses, costs and damages, whether absolute or contingent and of any nature whatsoever, which I and/or any Minor, now has or hereafter can, shall or may have, arising, directly or indirectly, out of or in connection with the participation of the Minor(s) in the Activities, including in respect of negligence, breach of contract, breach of any statutory or other duty of care or the failure on the part of the Grist Mill to take reasonable steps to safeguard or protect the Minor(s).
3. GENERAL. I expressly acknowledge and agree that this Release is intended to bind me, any other parent, guardian or legal representative of each Minor, and each Minor and be binding upon each of our heirs, administrators, assigns and representatives in the event of death or incapacity. I, the undersigned parent and/or legal guardian of the Minor(s), affirm that I am freely signing this Release. I have read this Release and fully understand that by signing this Release I am giving up legal rights and/or remedies which may otherwise be available to me and the Minor(s) in respect of any losses that we may sustain as a result of the participation of the Minor(s) in the Activities.

Permission to Photograph

Permission to Photograph

• I hereby grant to the Grist Mill the right to use the name, photograph and recording (video or otherwise) of each Minor, at any time, and from time to time, for the purpose of advertising, publicity, and for promotion of the Grist Mill and the Activities in any manner of media without compensation or advance notice.

"Signed" by: *

Date / Time *

Submit