PLEASE PRINT AND MAIL TO:
Lazy Mill Living Arts LLC
21 Lazy Mill Rd
Stannard Vt 05842
COURSE NAME AND DATE:________________________________
ADDRESS (IF DIFFERENT FROM PARTICIPANT):_____________________________________________________________________
PHONE (HOME):_________________________________ (CELL):___________________________
HOW DID YOU HEAR ABOUT US?_____________________________________________________
RELATIONSHIP TO CONTACT:___________________________________________________________________________
BACK-UP EMERGENCY CONTACT:____________________________________________________
RELATIONSHIP TO CONTACT:_______________________________________________________
Do you have any allergies (food, medication, insects, etc)? Yes No
If yes please explain what you are allergic to and the reaction:
Are you a vegan, vegetarian or do you have any other dietary concerns we should know about:
Are you currently under the care of a medical professional?
If yes, please explain.
Are you currently taking any medications?
If so, please list the medications and condition.
In the event of a medical emergency is there any additional medical history or problems we should be aware of?
Past operations or serious injury?
Physical or activity restrictions?
Date of last tetanus shot?
Do you have health insurance?
Name of insurance company:____________________________________________
Name of insured and relationship to you:_____________________________________
I hereby allow Lazy Mill Living Arts LLC to take and use my photograph in advertisements and on our website. YES NO
Rules and Regulations
Lazy Mill Living Arts, LLC will not allow illegal drugs and/or alcohol at classes, nor will we admit students who are under the influence of illegal drugs and/or alcohol. Lazy Mill Living Arts, LLC reserves the right to ask students who do not follow our safety guidelines, respect instructors and other students, and/or adhere to the guidelines set forth in class orientation, to leave the class without refund.
I _______________________________________________________________________(Print Name) agree to the above rules and regulations.
X ___________________ ______________________(Signature) __________ (Date)
RELEASE WAIVER: Please read carefully and initial each paragraph.
_______Lazy Mill Living Arts, LLC takes reasonable care to prevent serious injuries and to minimize accidents. I am fully aware that LMLA, LLC programs, even under the safest conditions possible, may be dangerous, and I hereby agree to knowingly and voluntarily accept full responsibility and assume all risks, including those caused by acts of God, injury, death, and/or loss to me and/or my property. I agree to obey the rules and regulations set down by LMLA, LLC in order to minimize these risks.
________I knowingly, voluntarily, and irrevocably waive any and all claims, of any sort whatsoever, arising from my participation in or observation of, any LMLA, LLC program. I certify that I am physically able to participate in the said LMLA, LLC programs despite the rigors and dangers inherent in such an undertaking. I accept all responsibility for any injury, death, and/or loss to me or my property, including by acts of God, for the rigors and dangers inherent in this undertaking.
In consideration of being permitted to participate in any way in the activities and training by LMLA, LLC Programs, I acknowledge and agree that:
______1. The risk of injury from the activity involved in LMLA, LLC Programs is significant, including the potential for permanent disability and death, and while particular protective equipment and personal discipline will minimize this risk, the risk of serious injury does exist;
______2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE of those persons released from liability herein, and assume full responsibility for my participation; and,
______3. I understand that the activities of LMLA, LLC Programs are physically and mentally intense. I agree to comply with all rules and regulations. If I observe any unusual or unnecessary hazard during my participation, I will bring such to the attention of the nearest staff member as soon as practical; and,
______4. I, for myself and my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS FROM LIABILITY LMLA, LLC, the instructors of LMLA, LLC classes, as well any volunteers, and the host of LMLA, LLC Programs , WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, except that which is the result of gross negligence and/or wanton misconduct.
______5. I understand and agree that this Release of Liability Agreement covers each and every LMLA, LLC activity and event in which I participate hereafter.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
X _________________________________________ Date Signed: _____________ Phone #: ____________________
_________________________________________________ ______________________________ _______________
ADDRESS CITY, STATE ZIP CODE
FOR PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)
All forms of outdoor activities such as, but not limited to, hiking, swimming, climbing, field games, and other outdoor activities have inherent risks and can be hazardous. Our staff is trained in dealing with emergency situations and will strive to safeguard your child‘s physical and psychological well being at all times. As the parent or guardian of the minor child named below, I am fully aware of these risks, and realize that injuries are a possibility no matter how attentive a caregiver or counselor may be. I accept the full responsibility for any such damage or injury of any kind that may result from the actions of the minor child enrolled in this program.
In the event of an emergency, I understand that LMLA will do all in their power to reach me and/or the emergency contacts I have provided. In the event that I cannot be located immediately, my signing below authorizes the staff of LMLA to procure emergency medical attention for the child named below.
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree not only to his/her release of Releasee but also to release and indemnify the Releasee from any and all liabilities incident to his/her involvement in these programs for myself, my heirs, assigns, and next of kin.
X _____________________________________________ _____________________________
PARENT/GUARDIAN’S SIGNATURE EMERGENCY PHONE #(S)
PARENT/GUARDIAN’S PRINT NAME
Date Signed: _____________________________
Course Enrollment Requirements and Cancellation Policy
All courses are filled on a first come first serve basis. The size of each class will be limited to a number that allows participants to receive
Course Enrollment Requirements and Cancellation Policy All courses are filled on a first come first serve basis. The size of each class will be limited to a number that allows participants to receive an exceptional level of experience and education.. Each student must sign a liability waiver prior to participation in a class. A $50.00 non-refundable deposit is required with your application form for workshops and a $100 non-refundable deposit for camps, the remaining balance will be due on the first day of the class. If you cancel your reservation for a workshop two weeks prior to the start of the course, you will be able to transfer the full amount of your deposit to another course. The transferable deposit may be applied toward the cost of another workshop within 12 months of the original course date. If LMLA is not notified of your cancellation two weeks prior to the class, you will be charged the full amount of your deposit. Please allow two weeks for the office to process your registration form and deposit. Your reservation will be confirmed with additional workshop or camp information. Full refunds are only made in the event that we need to cancel a workshop or camp. If a course is canceled Roots School is not responsible for any additional cost due to the cancellation or date change. Please return this application form with a deposit. Please make checks payable to Lazy Mill Living Arts, LLC.
All personal and medical information included in the registration form is used only by Lazy Mill Living Arts.LLC. Email and mailing addresses are never shared or sold with any other organization and will only be used by Lazy Mill Living Arts LLC.