COMMUNITY PLACE NORTHWEST HOLD HARMLESS AGREEMENT, WAIVER & RELEASE
Please initial on the line preceding each paragraph to acknowledge consent. Community Place Northwest (hereinafter CPNW), formerly Kids Place Northwest, is a non profit educational organization incorporated in the State of Washington. CPNW provides instruction in culinary arts (cooking), arts, crafts, gardening, music and other instruction for children, youth and adults.
______ I acknowledge that I and/or my child will be using sharp instruments (knives and other cooking equipment, gardening equipment, other equipment) and have access to heat sources (ovens, stoves, other cooking equipment, glue guns) and may come into contact with food allergens and other allergens as part of my and/or my child’s participation in the day camps and/or classes offered by CPNW.
______ I further acknowledge that I and/or my child may be coming into contact with farm animals, including but not limited to baby chicks, chickens, goats, ponies, horses, sheep, cattle as part of my and/or my child’s participation in the activities of the day camps and/or classes offered by CPNW.
______ In consideration of myself and/or my child being permitted to participate in private cooking and/or art/crafting and/or gardening and/or music and/or farm related activities and/or other activities associated with the day camps and/or classes offered by CPNW, I hereby waive, release and discharge any and all claims for damages or personal injury, death, or property damage which my child may have or which may hereafter accrue as a result of my child’s participation in said activity. This release is intended to discharge, in advance, Stephanie A. Johnson King, Susanna M. Munion, Community Place Northwest (formerly Kids Place Northwest), its volunteers, officers, directors, members and managers, vendors, venues included but not limited to Marion Grange Hall, Orting United Methodist Church, Buckley Culinary Center, Le Sorelle Inn, Wild West HipCamp, and all other members of its staff whether contracted or employed, from and against any and all liability arising out of or connected to in any way with any participation in said activity.
______ I understand that the activity that I and/or my child is participating in may be of a hazardous nature and/or include physical and/or strenuous activity, that serious accidents occasionally occur during the said activity; and that participants in the said activity can occasionally sustain personal injuries as a consequence thereof. Knowing the risks involved, nevertheless, I have voluntarily applied to allow myself and/or my child to participate in said activity, and I hereby agree to assume any and all risks of injury or death and to release and hold harmless, Stephanie A. Johnson King, Susanna M. Munion, Community Place Northwest (formerly Kids Place Northwest), its volunteers, officers, directors, members and managers, vendors, venues included but not limited to Marion Grange Hall, Orting United Methodist Church, Buckley Culinary Center, Le Sorelle Inn, Wild West HipCamp, and all other members of its staff whether contracted or employed, who might otherwise be liable to me. I further understand and agree that this Waiver, release and assumption of risks is to be binding on myself, my child(ren), my heirs and assigns.
______ I hereby grant Stephanie A. Johnson King, Susanna M. Munion, Community Place Northwest (formerly Kids Place Northwest), its volunteers, officers, directors, members and managers, vendors, venues included but not limited to Marion Grange Hall, Orting United Methodist Church, Buckley Culinary Center, Le Sorelle Inn, Wild West HipCamp, and all other members of its staff whether contracted or employed, all rights and consent to copyright, use, re-use, publish or re-publish, copy, exhibit or distribute all photographs and/or video of my child to be used for Community Place Northwest (formerly Kids Place Northwest), Marion Grange Hall, Orting United Methodist Church, Buckley Culinary Center, Le Sorelle Inn, Wild West HipCamp website(s), social media and any educational, training or promotional electronic or printed material without restriction as to frequency or duration of usage and without compensation. In consideration for your and/or your child’s participation in an event by CPNW and/or Stephanie A. Johnson King (instructor), and by signing this form, you acknowledge, agree and understand that your and/or your child’s participation is voluntary and you assume risks associated with the activity in which you and/or your child will be participating.
______ FOOD ALLERGIES AND SENSITIVITIES: Please contact us at least one week in advance if you and/or your child has food allergies or sensitivities. You are responsible for advising us of the type and severity of your/your child’s condition. We will try to accommodate you/your child to the best of our ability, but please understand that menus are prepared in advance, and last-minute changes are generally not accommodated. Reactions due to food allergies and sensitivities are included as risks associated with culinary classes (cooking), gardening classes, farm camps and homesteading activities. By signing this Waiver, I acknowledge that I have carefully read this three page Hold Harmless Agreement, Waiver and Release and fully understand its contents. I am aware that this is a release of liability and a contract between myself on behalf of myself and/or my child(ren) and Community Place Northwest (formerly Kids Place Northwest) and any staff member of the day camps and classes whether contracted or employed.
Print Student’s(s’s) Name(s) (All members of your family may be listed on one form. If student last names are different, please include both first and last names above. Thank you.) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________
Print Legal Guardian’s Name___________________________________________________
Guardian’s Email______________________________ Guardian’s Phone_________________ Guardian’s Signature___________________________________________Date___________
Does the participant have any allergies? Y / N If yes, please list _______________________________________________________________
Anything else that would require additional support from us? ____________________________________________________________________________
Emergency Contact Name_______________________________________________________
Emergency Contact Telephone __________________________
Who else is allowed to pick up your child(ren) from our events? _________________________________________________/__________________________
Name Phone