John Eaton Field Trip Tuesday June 3, 2024 Please fill out this waiver and click “Submit” Thank You! Participant Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Date of Birth* Month Day Year Gender*Age*If Participant is under 18, fill in parental info below:Parent #1 First Last Parent #1 Email Parent #1 Cell PhoneParent #1 Work PhoneParent #2 Name First Last Parent #2 Email Parent #2 Cell PhoneParent #2 Work PhoneEmergency Contact Name First Last Emergency Contact Phone*Health Information*Food allergies or other concerns, and any other health information you think we should knowIn consideration of participation in activities at Valley Mill Camp I agree to release and on behalf of myself, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE Valley Mill Camp, its officers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against Valley Mill Camp on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to the use of Valley Mill Camp facilities/equipment or participation in Valley Mill Camp programs whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees.* By checking here you agree that you read and understood the statement above In consideration of participation in activities at Valley Mill Camp, I, the undersigned participant or parent/legal guardian of the participant, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to Valley Mill Camp participation.* By checking here you agree that you read and understood the statement above I hereby certify that I have full knowledge of the nature and extent of the risks inherent in participation in activities at Valley Mill Camp and that I am voluntarily assuming said risks. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, or death, I sustain while participating in Valley Mill Camp and that by signing this agreement I HEREBY RELEASE Releasees from all liability for such loss, damage, or death. I further certify that the participant is in good health and that he/she has no conditions or impairments which would preclude safe participation in activities at Valley Mill Camp* By checking here you agree that you read and understood the statement above Electronic Signature Agreement* By checking the above checkbox, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. I agree that I am the Participant, or the Parent or Legal Guardian of the Participant, named above, that I am 18 years of age or older, and that I have the legal authority to grant this permission to Valley Mill Camp Inc* By checking here you agree that you read and understood the statement above. Name of Signer – Parent or Legal Guardian* First Last