CULINARY CAMP. Contact and Medical Information. Parent/Guardian s name: Work Phone: Home Phone: Cell Phone:

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Cody Boyd
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1 CULINARY CAMP Contact and Medical Information Child s name: Parent/Guardian s name: Work Phone: Home Phone: Cell Phone: In case of an emergency, when neither parent/guardian can be reached, please list the person who will take responsibility for your child. Name: Relationship to Camper: Phone: Alt. Phone: Address: Health insurance Company Name: Policy Number: Group Number: Primary Policy Holder: Allergies to food/medications: Please note that food prepared in the Culinary Camp may contain or come into contact with peanuts, tree nuts, dairy, wheat, gluten, eggs, and/or soy. Will your child need to take medication(s) during camp hours, and/or in the event of an allergic reaction (e.g., EpiPen)? If so, please provide detail: In case of medical emergency, we will call 911. If the situation warrants swift medical attention, your child will be taken to the nearest hospital where we will provide his/her medical information above. Parents will be immediately notified. In all non-emergency situations, the parents will be contacted. I,, the parent/legal guardian of, understand the terms outlined above, and hereby authorize emergency medical treatment for my child in the event I cannot be contacted to give permission to treat. I understand I will be financially responsible for the cost of such treatment.

2 Clinton Center Culinary Camp Parent/Guardian Consent and Indemnification Activities at the Clinton Center Culinary Camp may include, without limitation, cooking demonstrations and lessons (which include operating kitchen equipment), meetings, and potential off site excursions that may involve vehicular transportation or walking that include the risk of being exposed to potential hazards and risks inherent in such activities including but not limited to cuts, burns, other injury from kitchen equipment, allergic reactions, vehicle accidents, physical exertion, and contact with other participants. I hereby acknowledge these risks and expressly assume all risks, including personal injury and fatality, arising out of my child s participation in the Culinary Camp sessions and related activities. I acknowledge and agree that it is my responsibility to ensure that my child s clothing and equipment are appropriate and properly fitted for use in included activities. While the Culinary Camp provides lessons in kitchen safety, I represent and warrant that I have taught my child about basic kitchen safety and believe that he/she is capable of participating in the Culinary Camp. My child has been instructed to stop and request assistance if he/she is injured, or experiences any symptoms such as, but not limited to, dizziness, excessive fatigue, shortness of breath, pain or any other conditions that would make participation in activities difficult or unsafe to continue. I agree, for myself, my heirs, executors and administrators, not to sue and to release, indemnify, defend and hold harmless the William J. Clinton Center, the Clinton Foundation, and their affiliates, officers, directors, volunteers, employees and agents, and all sponsoring businesses and organizations and their agents and employees, from and against any and all liability, claims, demands, and causes of action whatsoever, arising out of or brought in connection with my child s participation in this event and related activities whether resulting from the negligence of any of the above or from any other cause. Furthermore, I authorize the use or publication of my child s name, image or voice as may be captured by photograph or recording while participating in this event in any medium for any purpose, including illustration, promotion or advertisement. The copyright(s) in such photograph, recording, illustration, promotion or advertisement or other material shall be owned by the William J. Clinton Center and the Clinton Foundation. The foregoing release and indemnification agreement shall be as broad and inclusive as is permitted by the State of Arkansas. If any portion of it is held invalid, the balance shall continue in full force and effect. I have read, understand and agree to the terms of this Agreement. I am the legal guardian of the participant, and I hereby consent to his/her participation. I have read and explained the foregoing release and indemnification agreement to my child, and I hereby agree to its terms on behalf of myself and the participant. Parent/Guardian s Printed Name Signature Date Participant s Printed Name Date Participant s Signature (required if 18 years or older)

3 Hortus, Ltd. and P. Allen Smith 1722 South Broadway Little Rock, AR PARTICIPANT RELEASE FORM For value received, I hereby grant to Hortus, Ltd. the irrevocable and unrestricted worldwide right to use in any manner whatsoever any and all photographs or video in which I may be included or my likeness may otherwise appear. This grant includes without limitation the right and permission to publish and use such photographs/video in whole or in part, modified or altered, either by themselves or in conjunction with other photographs/video in any medium or form of distribution, now known or in the future contemplated, including without limitation all promotional and advertising uses, other trade purposes and in the distribution of video to commercial broadcast television and cable stations as well as Public Broadcasting stations for transmission to home viewers. I further grant to Hortus, Ltd. the right to use my name in connection with such photographs and/or video and to copyright any or all such materials. I waive the right to inspect or approve any use of such materials. I forever release and discharge Hortus, Ltd., its successors, assigns, employees, directors and agents from any and all claims, actions and demands arising out of or in connection with the use of said photographs and/or video, including without limitation any and all claims for invasion of privacy, misappropriation of publicity rights, or libel. I represent and warrant to Hortus, Ltd. that I have all necessary right and authority to grant the rights granted herein. To the extent that any third-party claim, action, or demand arises out of or in connection with such granted rights, I indemnify and hold harmless Hortus, Ltd., its successors, assigns, employees, directors and agents from such claim, action or demand. I sign this agreement in consideration of having the opportunity to participate in the photographs and/or videotaped segment, and I waive all rights to royalties or any compensation. PLEASE PRINT Participant s Name Participant s MAILING Address (including City, State, Zip) Participant s Address Participant s Phone -CONTINUED OVER-

4 Please check the correct option below and complete the following information: (1) I represent that I have reached the age of eighteen years, and that I have read and fully understand the terms of the this release. 2) I represent that the participant is a minor and that I am the parent or duly authorized guardian or representative of the participant, and that I have read and fully understand the terms of this release. 3) I represent that I am the (Title) at and (School Name) I hereby attest that the school has on record a consent form for all students that will be video taped or photographed and hereby sign for these students as the participant. Participant s Signature Participant s Title Date Parent/Guardian s Name Parent/Guardian s Address Parent/Guardian s Address Parent/Guardian s Phone Parent/Guardian s Signature Date Witness: Date: FOR PRODUCTION USE: Project name/title:

5 Youth Volunteer Consent & Release Form (Please have a parent/guardian sign this form and bring it with you when you come to volunteer. You will not be allowed to volunteer if we do not have a signed consent form.) Dear Parent or Guardian: I grant permission for, (print child s name) to enter the Arkansas Foodbank, including but not limited to the offices and warehouse, located at 3801 West 65 th Street, Little Rock, AR 72209, and to participate in volunteer activities to be held on (date(s)). I know the risks of injury to my person and property that may be sustained in connection with the stated and associated activities in and about the premises. In consideration of the permission granted to me to enter the premises and participate in the stated activities, I, for myself, my heirs, administrators, and assigns, release and discharge the owners, operators, and sponsors of the premises, activities, and vehicles and equipment in the same and their respective agents, officers, and officials, and all other participants in the stated activities of and form all claims, demands, actions, and causes of action of any sort, for injury sustained to my person and/or property, during my presence on the premises and my participation in the stated activities due to negligence or any other fault. I represent and certify that my true age is 18 years or over, and if I am under the age of 18 years, I represent and certify that I have the permission of my parent and/or guardian to participate in the stated activities, and that they have full knowledge of the stated activities. I certify that my attendance and participation of the stated activities is voluntary, and that I am not, in any way, the employee or agent of the owner, operators, or sponsors of the premises and the activities, vehicles and equipment, in the same. I have read and understand this consent and release and have reviewed the Arkansas Foodbank Volunteer Policies with my child. My child has agreed to comply with these guidelines while serving at the Arkansas Foodbank. The Arkansas Foodbank also has my permission to use any photographs or videotape taken during volunteer activities in any and all publicity. PLEASE PRINT THE FOLLOWING: Parent/Guardian Name Emergency Contact name and Phone Number Parent/Guardian Signature Date Signed Updated by: Polly Deems, January, 2016

CHINESE CULTURE CAMP REGISTRATION FORM

CHINESE CULTURE CAMP REGISTRATION FORM Child s Information: Last Name: First Name: MI: Nickname: Gender: M F Birth Date: Age: Primary Phone #: School Attending: Grade: Parent(s)/Guardian(s) Information: