Adventure Club - Free Range Registration Form Please enable JavaScript in your browser to complete this form.Choose an Adventure Club *--- Select Choice ---Free Range - Stompers (1:30 - 3:00PM)Free Range - Wildlings (3:30 - 5:00PM)Child's Name *FirstLastChild's Date of Birth *Use format mm/dd/yyyyChild's Age *Enter child's age in years.Child's School *Ex: Lamplighter Montessori, Snowden Elementary, Homeschool, etc. Child's T-Shirt Size *--- Select Choice ---Youth X SmallYouth SmallYouth MediumYouth LargeYouth X LargeAdult SAdult MediumAdult LargeAdult X LargeParent/Guardian Name *FirstLastParent/Guardian Email *Parent/Guardian Phone and Emergency Contact *10 Digit Phone NumberSecondary Emergency Contact Name and Phone *Name and 10 Digit Phone NumberApproved Pick-Up Adults *Name (first & last) and Phone Number Does your child have any allergies? *NoYesIf yes, please list all known allergies and any relevant information about reactions or treatment.Does your child have any medical diagnosis, medications, or other health/safety information we should be aware of while your child is in our care? *NoYesIf yes, please provide details, including any emergency medications such as inhalers.Photo Permission *--- Select Choice ---Adventure Club is permitted to take photos of my child.Adventure Club is NOT permitted to take photos of my child.Photo Sharing Permission *--- Select Choice ---Adventure Club is permitted to use photos of my child for promotional purposes.Adventure Club is NOT permitted to use photos of my child for promotional purposes.Insect Repellent Permission *--- Select Choice ---I give permission for Muddy Boots Adventure Club to apply DEET-free insect repellent to my child as needed during Adventure Club.I DO NOT give permission for Muddy Boots Adventure Club to apply DEET-free insect repellent to my child as needed during Adventure Club. & Permission of Adventure Club Participation Agreement & Waiver *I agree and give my permissionMy child has permission to participate in Adventure Club, an enrichment program that may include outdoor exploration, nature play, light hiking, climbing on natural features, group games, and other physically active activities held on or near school grounds.Restroom Acknowledgement *I agree and give my permissionI acknowledge that there is no on-site restroom at Urban Roots and that my child may need to use a private, designated outdoor area when needed.Outdoor & Woods Exploration Permission *I agree and give my permissionI understand that activities may take place in wooded and natural areas that may include uneven ground, roots, rocks, mud, sticks, thorns, insects, and occasionally litter or debris such as broken glass or rusted materials. I give permission for my child to explore these spaces under supervision and understand that minor scrapes or bumps are a normal part of outdoor play.Special Activity Permission *I agree and give my permissionI understand that Adventure Club may include supervised activities such as barefoot play, tree climbing, campfires, identifying and tasting edible plants, using age-appropriate tools, such as shovels and garden shears, and riding bicycles with proper safety gear. I give permission for my child to participate in these activities when deemed appropriate by the instructor.Assumption of Risk *I agree and give my permissionI understand that participation in outdoor and physical activities involves inherent risks, including but not limited to falls, scrapes, insect bites, allergic reactions, weather exposure, interactions with the public, and other accidental injuries. I voluntarily accept and assume these risks.Release and Waiver of Liability *I agree and give my permissionIn consideration of my child’s participation, I release and discharge Sydney Roberts and any assistants, volunteers, or instructors from liability for injuries, losses, or damages arising from participation, except in cases of gross negligence or willful misconduct.Hold Harmless & Indemnification *I agree and give my permissionI agree to indemnify and hold harmless Sydney Roberts from any claims, costs, damages, or expenses resulting from my child’s participation.Medical Authorization *I agree and give my permissionI authorize the instructor to provide basic first aid and address minor medical concerns that arise during Adventure Club. If I cannot be reached, I authorize the instructor to take reasonable steps to address the situation and seek medical care when reasonably necessary.Health Disclosure *I agree and give my permissionI agree to provide accurate and updated information regarding any medical conditions, allergies, medications, or special needs that may affect my child’s safety or participation.Behavior Expectations *I agree and give my permissionAdventure Club is built on kindness, cooperation, and safe choices. If my child’s behavior creates a safety concern, the instructor may suspend them from Adventure Club for one week. If unsafe or disruptive behavior continues after suspension, the child may be dismissed from the program. Refunds are not guaranteed in cases of suspension or dismissal.Independence and Self Regulation *I agree and give my permissionI understand that Adventure Club encourages children to develop independence, resilience, and problem-solving skills. My child is able, within reason, to self-regulate, work through minor frustrations, and resolve age-appropriate interpersonal problems with limited adult assistance. I understand that the instructor will provide support and guidance when needed, but my child should be able to recover from minor setbacks and continue participating with appropriate encouragement.Weather & Outdoor Conditions *I agree and give my permissionActivities may take place outdoors in varying weather conditions. I agree to provide appropriate clothing and understand that activities may be modified, relocated, or canceled if conditions are unsafe. Cancellations will not result in a refund, partial or otherwise.Pickup Policy *I agree and give my permissionI agree to pick up my child promptly at the designated time. Children will only be released to authorized individuals, and identification may be required at pickup.Refund Policy *I agree and give my permissionI understand that all payments made for Adventure Club are non-refundable. No refunds, credits, or partial refunds will be issued for absences, illness, late enrollment withdrawal, suspension, dismissal, weather-related cancellations, schedule changes, or cancellation of an individual activity. By registering my child, I acknowledge and agree to this refund policy.Release and Waiver of Liability *I agree and give my permissionIn consideration for participation in activities occurring at or in connection with Urban Roots of Tennessee, the undersigned parent or legal guardian, on behalf of themselves and the participating minor child, knowingly and voluntarily assumes all risks associated with participation and agrees, to the fullest extent permitted by law, to release, waive, discharge, indemnify, and hold harmless Urban Roots of Tennessee, Golden Gate Development Corporation, Golden Gate Cathedral, and each of their respective officers, directors, employees, agents, representatives, volunteers, affiliates, successors, and assigns from and against any and all claims, demands, liabilities, damages, losses, costs, or causes of action arising from or related to the participant’s involvement in the activities, including claims involving personal injury, illness, property damage or loss, permanent disability, or death, except to the extent prohibited by applicable law.Legal Guardian Agreement & Confirmation *FirstLastBy entering my name above, I confirm that I am a legal guardian of the child who will be enrolled in Adventure Club, and I have read, understand, and voluntarily agree to this Participation Agreement Form.Submit