2024 Child Participant Form

* Indicates required field

Name of Child *

First

Last

Grade/Age *

Name of Parent/Guardian *

First

Last

Allergies *

Current Medications Taken *

Known Medical/Behavioral Conditions *

Reason For Medication *

Address *

City *

State *

Zip *

Email Address *

Alternate Email Address *

Main Phone Number *

Alternate Phone Number *

Emergency Contact Person (2nd Parent/Guardian Name Please) *

Emergency Contact Phone Number (2nd Parent/Guardian Phone Number Please) *

PERMISSION FOR MEDICAL TREATMENT
BY PARENT/LEGAL GUARDIAN OF MINOR CHILD
FOR ROCK HOLLOW WOODS ENVIRONMENTAL LEARNING CENTER

I grant Rock Hollow Woods Environmental Learning Center, its employees, agents, interns, volunteers, directors or officers (collectively, “Rock Hollow Woods”) permission to administer basic first aid when applicable, including the treatment of minor cuts, scrapes, burns (including sunburns) and stings. Medication will not be administered by Rock Hollow Woods at any time. I hereby give permission to medical personnel and Emergency Medical Services selected or contacted by Rock Hollow Woods to provide transportation and treatments for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician and hospital where I am transported to secure and administer treatment, including hospitalization and surgery, for my child. I agree to assume financial responsibility for all medical and hospital expenses.

I AGREE TO THESE MEDICAL TREATMENT TERMS *

I Agree

WAIVER AND RELEASE FROM LIABILITY BY PARENT/LEGAL GUARDIAN OF MINOR CHILD FOR ROCK HOLLOW WOODS ENVIRONMENTAL LEARNING CENTER

I grant permission for my minor child, named below, to participate in all activities and events conducted by Rock Hollow Woods Environmental Learning Center, its employees, agents, interns, volunteers, directors or officers (collectively, “Rock Hollow Woods”) that may include, but are not limited to, hiking, stream exploration, woodland creations, campfires, and visits to neighboring adjacent properties for educational purposes.

I am aware of the nature of the activities, and events for which I am registering my child and I understand that accidents and injuries may occur as a result of participation in such activities and events.

Therefore, on behalf of myself and my child, I agree to assume all risks related to said participation. I hereby waive, release, absolve, indemnify and hold harmless Rock Hollow Woods from any and all liability for personal injury, or property damage which I or my child may have, or which may hereafter accrue to me or my child as a result of participation in any of the activities or events conducted by, on the premises of, or for the benefit of Rock Hollow Woods, even though that liability may arise as a result of Rock Hollow Woods’ negligence or carelessness.

I further agree that this waiver, release and assumption of risk shall be binding upon my and my child’s heirs and assigns. I also hereby agree to indemnify and hold harmless Rock Hollow Woods against all claims, damages, losses and expenses, including attorney’s fees, which may incur as a result of my child’s participation in the said activities/events. This waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct.

This is a Pennsylvania Contract and shall be governed by the laws of the Commonwealth of Pennsylvania. Further, in the event that a court of competent jurisdiction finds liability on the part of Rock Hollow Woods, despite the existence of this waiver, I agree that the amount of any recovery for any such injury shall be limited to the amount that the liability carrier covering such injury is required to pay under Rock Hollow Woods’ general liability policy. I further intend that this waiver and release shall be effective immediately.

I fully assume the risks, both known and unknown, of exposure, illness or death related to infectious diseases, including but not limited to MRSA, influenza, and COVID-19, even if arising from the negligence of the released parties or other participants.

I HAVE READ AND UNDERSTAND THE ABOVE WAIVER AND RELEASE. BY CHECKING THE BOX BELOW, I AM SIGNING THIS WAIVER AND RELEASE VOLUNTARILY AND BY SIGNING IT AGREE THAT IT IS MY INTENTION TO GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN ROCK HOLLOW WOODS’ ACTIVITIES/EVENTS AND TO ASSUME AND ACCEPT ALL RISKS ASSOCIATED THEREWITH. IT IS MY INTENTION TO EXEMPT AND RELIEVE ROCK HOLLOW WOODS FROM ALL LIABILITY.

I AGREE TO THESE LIABILITY TERMS *

I Agree

PERMISSION TO USE PHOTOGRAPHS BY PARENT/LEGAL GUARDIAN OF MINOR
FOR ROCK HOLLOW WOODS ENVIRONMENTAL LEARNING CENTER

I grant permission to Rock Hollow Woods Environmental Learning Center, its employees, agents, interns volunteers, directors and officers (collectively, “Rock Hollow Woods”) to photograph and/or videotape my minor child, and to use my child’s name, image and/or likeness for any purpose in any and all of Rock Hollow Woods’ publications, including its website, and marketing and promotional materials, and in any and all other media now known or hereafter
invented. I release and forever discharge Rock Hollow Woods from any claim, suit, demand or action arising from any and all such uses, including without limitation any claims for libel or violation of any right of publicity or privacy.

PHOTOGRAPH/VIDEO CHILD *

YES, I Do. NO, I Do Not.

I grant permission for Rock Hollow Woods to release information on my child to news agencies for publication of human interest stories, awards, or special events or activities involving my child, as well as to release my child’s name and/or picture for special news purposes. I release and forever discharge Rock Hollow Woods from any claim, suit, demand or action arising from any and all such uses, including without limitation any claims for libel or violation of any right of publicity or privacy.

RELEASE INFORMATION *

YES, I Do. NO, I Do Not.

I hereby warrant that I am a legal competent adult and a parent or legally appointed guardian of the minor, and that I have every right to contract for the minor in the above regard. This release shall be binding upon the minor and me, and our respective heirs, legal representatives, and assigns.

PARENT/GUARDIAN RELEASE AGREEMENT *

I Agree

Submit