MAIL-IN REGISTRATION FORM For Summer Programs at the Bowers School Farm – 2012 (please fill out a separate form for each child & be sure to register a week in advance of program) Complete the form below and make a copy for your records.

Parent(s) Name: _________________________________________________________________________________________________ Last

First Name(s)

Address: _______________________________________________________________________________________________________ Street Address

City

Home Phone: ______________________

State

Zip

Cell Phone: ________________________ Work Phone: ____________________________

Email Address: __________________________________________________________________________________________________

Person(s) other than parent to whom the child may be released (please list ALL persons, continuing on the back if necessary, as this is the only form that will be used. No call-ins or separate letters will be accepted): Name Relationship to child Phone Number

_____________________________________________________________________________________________

Child’s Name: ___________________________________________ Last Grade Child Completed: _______________

Circle: Male

Female

Circle T-shirt Size: (we will try to do our best to accommodate your size request, but due to inventory, the t-shirt your child receives may be one size larger) YOUTH: SMALL MEDIUM LARGE EXTRA LARGE ADULT: SMALL MEDIUM LARGE EXTRA LARGE 3-DAY PROGRAMS - $150 (for 3 days) Mon/Tues/Wed - 9:00 am to 4:00 pm

July 9, 10 & 11 July 16, 17 & 18 July 23, 24 & 25 July 30, 31, Aug 1

Aug 6, 7 & 8 Aug 13, 14 & 15 Aug 20, 21 & 22 Aug 27, 28 & 29

From the above, provide your 1st, 2nd and 3rd preferred dates: 1st choice: ___________________ 2nd choice: ___________________ 3rd choice: ___________________

2-DAY PROGRAMS - $100 (for 2 days) Thurs/Fri - 9:00 am to 4:00 pm

July 5 & 6 July 12 & 13 July 19 & 20 July 26 & 27

Aug 2 & 3 Aug 9 & 10 Aug 16 & 17 Aug 23 & 24

From the above, provide your 1st, 2nd and 3rd preferred dates: ______________ 1st choice: 2nd choice: ______________ 3rd choice: ______________

5-DAY PROGRAM - $250 (for 5 days) Mon thru Fri – 9:00 am to 4:00 pm

July 9th week July 16th week July 23rd week July 30th week

Aug 6th week Aug 13th week Aug 20th week Aug 27th week

From the above, provide your 1st, 2nd and 3rd preferred dates: ______________ 1st choice: 2nd choice: ______________ 3rd choice: ______________

Please mail a check, payable to “Bloomfield Hills Schools” and be sure to include your driver’s license number and check number on the memo line. Your check should be mailed, with this form, to: Bowers School Farm Summer Programs 1219 E. Square Lake Rd. Bloomfield Hills, MI 48304 For further information, visit our website at www.farm.bloomfield.org or contact us through: • •

Email: [email protected] Phone: 248.341.6475

HEALTH INFORMATION AND LIABILITY WAIVER

For office use only: Last Name: _______________ Circle: 2-day program * 3-day program * 5-day Dates attending: ____________________ Does your child have any conditions that require medication or special precautions: YES NO

Child’s Name: _________________________________________ Last First

If yes, please explain:

Address: _____________________________________________ Street Address _____________________________________________________ City/Zip

PARENT/GUARDIAN INFORMATION: Name: _______________________________________________ Last First

Does your child have any allergies (medications, food, bee stings, etc) that we should be aware of: YES NO If yes, please explain:

Primary Phone: ________________________________________ Alternate Phone: _______________________________________

EMERGENCY CONTACT INFORMATION: Name: _______________________________________________ Last First Primary Phone: ________________________________________ Alternate Phone: _______________________________________

Please list any other information that would be helpful to our staff in working with your child (continue on back if needed):

Doctor Name & Phone Number: _____________________________________________________ Insurance Co: _________________________________________ Policy No: _________________________________ Hospital Preferred in case of emergency: _______________________________________________________________

CONDITIONS OF PARTICIPATION As the parent(s) or legal guardian(s) of a child who wishes to participate in the Summer Program at the Bowers School Farm (the Program), we agree to the following conditions for our child’s participation. Nature of Activities and Discipline. We understand and agree that some Program activities may be strenuous and that our child is physically and psychologically fit to participate. We also understand and agree that, if our child engages in misconduct, the Program may remove our child from activities and/or the Program, in its sole and exclusive discretion. Medical Issues. We affirm we have listed all known medical issues pertaining to our child on this form. We understand and agree the Program will not administer or maintain medication to or for our child, except according to the terms of a mutually agreeable and completed health care plan, 504 Plan or IEPT Report we have delivered to an appropriate Program staff member. Separately, we give our permission and consent for Program staff to provide or authorize such first aid and emergency medical treatment as may be deemed warranted and, further, accept full financial responsibility for any treatment so provided. (CONTINUED ON NEXT PAGE)

Release and Indemnification. We release the Bloomfield Hills School District (including its employees, agents and representatives) of and from any and all claims and liabilities whatsoever (including negligence claims and claims for wrongful death) arising from or relating to our child’s participation in the Program. We also agree to indemnify the District (as defined), and hold it harmless, of and from any and all claims and liabilities whatsoever (including negligence claims and claims for wrongful death) arising from or relating to our child’s participation in the Program. Pick Up Time. We understand and agree we will pick up our child between 4:00 and 4:10 p.m. each day the Program is in session. We agree to pay the Program $1.00 per minute for each minute we arrive later than 4:10 p.m. to pick up our child, payable immediately. We also agree our child may be dropped by the Program in the event our child is picked up late more than once or in the event will do not pay the required late fee as required. Refund Policy. We understand the agree refunds (full or partial) are in the sole and exclusive discretion of the Program and, when provided, will be provided in the form of credit toward an alternate week for the current or the following summer, rather than cash. We also understand and agree that no refund will be provided in cases where the Program exercises its discretion to remove or drop our child from the Program.

Equine Activity Agreement and Release In consideration of my participation in equine and related activities at The Charles L. Bowers School Farm (hereinafter “Farm”), which I understand and acknowledge could be hazardous to my health and may result in bodily injury, I agree to assume all risks of injury arising out of such participation. I further agree, for myself and my heirs, assigns and legal representatives, to hold harmless the Bloomfield Hills School District, its Board Members, administrators, employees, agents, independent contractors and the Farm or anyone connected with its operation, from any and all claims and causes of actions of any nature for any and all personal injury or illness, including death, which may occur or which may be aggravated during participation in equine and related activities, either on or off the premises of the Farm. I further agree to indemnify the Bloomfield Hills School District, its Board Members, administrators, employees, agents, independent contractors and the Farm and its agents, employees, servants or anyone connected with its operation, for any costs, expenses, damages or legal fees which may be incurred as a result of any breach or violation of this Agreement and Release, if such breach results in injury or death to any person(s) engaged in equine or related activity at the Farm, without regard to whether such injury or death is alleged to have resulted from any act of negligence of the Farm, by its employees, agents, servants or anyone connected with its association. I further agree not to invite or permit any other person(s) to enter the Farm premises or to engage in any equine activity as my guest. Any such participation shall be deemed a trespass unless such person(s) execute(s) an “Equine Activity Agreement and Release” form. WARNING Under the Michigan Equine Activity Liability Act, an equine professional is not liable for any injury to or the death of a participant in an equine activity resulting from an inherent risk of the equine activity (PA 351 of 1994). I have read and understand the above terms of the Agreement and Release, and I agree to such terms.

_________________________________ Parent or Legal Guardian Dated: ___________________________

_________________________________ Parent or Legal Guardian Dated: ___________________________

_______________________________ Program Witness Dated: __________________________