Participant Name:_____________________________________________Male/Female____________

Date of Birth:_______________________________Age:______________Grade (Fall 12-13):___________

Parent/Guardian Name_________________________________________________________________

Mailing Address_______________________City:____________________State_________Zip:_______

Home Phone:___________________________Mother Work/Cell Phone:________________________

Father Work/Cell Phone:___________________________Email Address:_______________________

IMPORTANT! In an emergency situation, the above numbers will be called. Please provide additional Emergency Information below in case we are unable to reach anyone at the above numbers. Name:____________________________________Relationship:_________________________________ Phone:____________________________(if different than those provided above).

Medical conditions that we should be aware of (allergies: food/insects, behavioral etc.)_______________________ ________________________________________________________________________________________________

Insurance Company Name:______________________________Policy Number:_________________

Program Name Dates Fee

__________________________________________________________________ $_________

__________________________________________________________________ $_________

T-Shirt ($10.00 each)______________Size: YS YM YL S M L $_________
Total Due: $_________
LESS $75 non-refundable deposit per session: (_________)
Balance Due: $_________

PAYMENT METHOD: Cash:____________Check (payable to DalbyFarm):_________________

REFUND POLICY:
The program fee includes a nonrefundable $75.00 enrollment fee. If you cancel for any reason before the program begins, your refund (less the $75.00 enrollment fee) is calculated by the following schedule: 60+ days in advance, 100 percent; 21 days in advance, 50 percent; less than 21 days in advance, no refund. All cancellations must be received in writing. We reserve the right to cancel a session due to low enrollment. In this case, a full refund (including enrollment fee) will be given. Refunds are not given for sick or absent days.

PLEASE CONTINUE TO NEXT PAGE. RELEASE MUST BE COMPLETED AND SIGNED TO PARTICIPATE IN PROGRAM. THANK YOU!
OFFICE USE ONLY

Date received:____________Payment Received:__________________Release Signed: Y N
Received By:______________Date Processed:_________________Processed By:_______________

IN SIGNING THIS FORM BELOW, PARENTS/GUARDIANS AGREE TO, UNDERSTAND AND ACCEPT THE FOLLOWING:
· I understand that my child may not attend the program until Dalby Farm receives all of the properly completed forms and any and all outstanding payments.
· I understand that the Program Director reserves the right to dismiss a participant if, in her judgment, the participant’s behavior interferes with the rights or safety of others, or the smooth functioning of a group or activity, or violates the program’s principles of conduct, or if the child has special needs that were not brought to the Program Director’s attention at the time of registration.
· I authorize Dalby Farm to make, have, use, publish and reproduce photographs, slides and videotapes of my child for Dalby Farm records or public relations purposes.
· I understand that it is my responsibility to bring any special concerns about my child to the Director’s attention at the time of Registration.
· I understand that I cannot send my child to Dalby Farm when he/she is ill.
· I give permission for my child to receive first aid treatment as needed and I authorize them to be taken to a doctor or hospital and treated if I cannot be reached in an emergency.
PARENTAL CONSENT, RELEASE FROM LIABILITY AND INDEMNITY AGREEMENT

I/We, the undersigned father, mother or guardian (circle or insert legal relationship to child, e.g., “parent,” “guardian”) of____________________(insert name of student) (“my child”), a minor, do hereby consent to my child’s participation in voluntary learning programs of Dalby Farm.
I/We also agree to forever RELEASE Dalby Farm of Scituate Mass., their employees, officers, volunteers and any and all claims, actions, rights of actions, and causes of action, damages, costs, loss of services, expenses, compensation, and attorneys’ fees that may have arisen in the past, or may arise in the future directly or indirectly, from known and unknown personal injuries to my child or property damage resulting from my child’s participation in the said Dalby Farm’s voluntary learning programs which I/we may now or hereafter have as the parent(s) or guardian(s) of said minor child and which said minor child has or hereafter may acquire either before or after reaching majority.
I/We also promise, to INDEMNIFY, REIMBURSE, DEFEND, and HOLD HARMLESS the Releasees against any and all legal claims and proceedings of any description that may have been asserted in the past, or may be asserted in the future, directly or indirectly, including damages, costs and attorney’s fees, arising from personal injuries to my child or property damage resulting from my child’s participation in Dalby Farm’s, of Scituate, voluntary learning program or administration of first aid.
I/We further affirm that I/we have read this Registration Form, Parental Consent, Release from Liability and Indemnity Agreement, and that I/we understand the contents of this Agreement. I/We understand that my child’s participation in this program is voluntary and that my child and I/we are free to choose not to participate in said programs. By signing this Agreement, I/we affirm that I/we have decided to allow my child to participate in Dalby Farm’s learning program with full knowledge that the Releasees will not be liable to anyone for personal injuries and property damage to my child or I/we my suffer in voluntary Dalby Farm learning programs.

Signature of Parent(s) or Guardian(s):__________________________________Date:_______

Please PRINT your name & relationship here :______________________________________

Of Student/Participant Name (Printed):____________________________________________