Hawthorn Farm: Youth Program Registration, Release & Waiver Form

Hawthorn Farm Youth Program Registration Form
Program Name *
Program Start Date*

MonthDayYear
Date
Name of Participant*

First NameLast Name
Age and birthdate*
Programs are age specific
Gender and Pronouns*

Male he/himFemale she/herNon-binary they/themOther
Name of Parent of Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Name of 2nd Parent or Guardian*

First NameLast Name
Address of 2nd Parent or Guardian - if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of 2nd Parent or Guardian*

Area CodePhone Number
Email of 2nd Parent or Guardian
If they wish to receive program emails
How did you hear about our programs?
What are your hopes for your child for this program? 1st time registrations - please answer
Does your child have any special needs we should know about to serve them better? 1st time registrations - please answer
Has your child had any behavioral issues or problems with other children? What has worked to help them through these in the past?*
Please describe your child's gifts and passions 1st time registrations - please answer
Please tell us anything else you would like us to know.

Hawthorn Farm Youth Release

Emergency Contact Information
Name*

First NameLast Name
Relationship to Participant*
Phone Number(s)*

Area CodePhone Number
Medical or other conditions we need to know about? Please list and describe Allergies, Asthma, Diabetes,recent injuries or hospitalizations, current medications, or any physical or mental limitations: *
RELEASE, INDEMNIFICATION AND WAIVER FORM:
I, the undersigned, hereby acknowledge that I have been advised and fully understand that certain elements of danger
are inherent in the activities sponsored by Hawthorn Farm, LLC which are beyond the control of the agents, students,
tenants, and employees of Hawthorn Farm, LLC, and that participation by myself or my family in any activities may
entail unavoidable risk of personal injury, death, and loss of or damage to property. These risks include, but are not
limited to, insect and animal bites and stings, forces of nature such as but not limited to lightning and extreme weather
conditions, use of hand tools and power tools, and any hazard present in the wilderness or suburban farm settings.

I hereby assume all risks of injury and death to my child and loss of or damage to property arising out of my child’s
participation in such activity and I agree to indemnify, hold harmless Alexia Allen and Daniel Kirchhof and any tenants
and employees there-of or Hawthorn Farm, LLC (“Releasees”) from and against all claims arising from any occurrence
causing damage or injury to myself, my child(ren) or to any party participating in said event or any third parties injured
as a result of my child’s actions. I also confirm that by signing as a Parent/Guardian, I release, waive, and discharge
the Releasees for all claims any parent of my child(ren) might have as a parent or guardian for injury to any child for
whom I have signed. I further agree to repair or reimburse Hawthorn Farm LLC or Alexia Allen for any and all
damages that my child(ren) or family causes to the property at 17340 NE 195th St, Woodinville WA 98072 or wherever
the specific program may be held.

In the event that my child requires medical attention while participating in this program, I hereby grant permission to
Hawthorn Farm, LLC and its representatives to provide for the rendering of such care, including diagnostic procedures,
surgical and medical treatment, by authorized medical staff or their designees, as may in their professional judgment
be necessary. I hereby acknowledge that I am responsible for all reasonable expenses in connection with care and
treatment rendered during this period.

I grant permission for Alexia Allen, Daniel Kirchhof and Hawthorn Farm to use images and photos of myself or my
children for promotion of Hawthorn Farm website, programs or newsletters.

Prior to signing below, I have read and understood the terms and conditions of this Release, Indemnification, and
Waiver, understand by signing below I am waiving certain legal rights I may have against the Releasees, and I agree
to subscribe to all the terms and conditions set out above.
Parent/Guardian Signature*

Clear
Parent/Guardian Name *

First NameLast Name
Dated*

MonthDayYear
Date

Congratulations, you're almost finished!

To apply for this program, please click the button below to submit this form, We'll review your registration and send a confirmation email within 2 weeks. Thanks for choosing Hawthorn Farm Youth Programs!
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Hawthorn Farm Youth Program Registration Form

Hawthorn Farm Youth Release

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