COMMON GOOD CITY FARM

YOUTH APPLICATION and EMERGENCY INFORMATION

(This information is completely confidential.)

Please drop off at Common Good City Farm, on V Street NW between 2nd and 4th. Or mail to P.O. Box 26030, Washington DC 20001. Or email to

Please Print Clearly

Name of Child / Date of Birth / Age / School / Grade
Phone / Address

At this time of year, everyone working in the garden will be exposed to pollen, insects, and heat. As a result, there is a potential threat of bee stings, bug bites, poison ivy, allergic reactions, etc. For your child’s own safety, the information below concerning your child would be highly beneficial in case of an emergency. Occasionally, we may need to contact you in the event of a scheduling change or if we need to check in with you regarding your child’s gardening experience. Please type or print clearly.

Parent Information:

Parents/Guardian Name(s) :______

Address: ______

Phone: home ______work ______cell: ______

Email: ______

Who should be contacted in case of emergency?

Name: ______

Address: ______

Phone: home ______work ______cell: ______

What kind of allergies does my child have (medical, food and/or environmental)?

______

My child does not have any allergies: ___

Is there any other information regarding my child’s medical history that the staff and volunteers of the Common Good City Farm staff should know?

______

______

Please list any special needs or medical conditions that you are aware your child has:

______

______

Photography Release

Throughout the summer Common Good City Farm takes pictures to illustrate the many children who have benefited from the program.

I give COMMON GOOD permission for any responsible use of photographs and video taken at COMMON GOOD sponsored events in which I appear, or in which my family member and/or daughter/son appears. I understand that the photographs and video may be used in displays, publications, or sent to the press for publication in a newspaper or use on television.

_____Initial Parent or Guardian ______Date

Parent Agreement

I understand that my daughter/son must follow the Common Good City Farm Youth Rules –

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COMMON GOOD CITY FARM

YOUTH APPLICATION and EMERGENCY INFORMATION

(This information is completely confidential.)

Please drop off at Common Good City Farm, on V Street NW between 2nd and 4th. Or mail to P.O. Box 26030, Washington DC 20001. Or email to

  • Have fun
  • Learn and work together
  • Treat everybody with respect and kindness
  • Listen and follow directions
  • If you don't know, ask
  • No weapons or drugs on the farm
  • Use tools properly and under the supervision of an adult
  • Don’t use the water hose without permission
  • Clean-up after yourself
  • Will not yell at or hit other children or staff

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COMMON GOOD CITY FARM

YOUTH APPLICATION and EMERGENCY INFORMATION

(This information is completely confidential.)

Please drop off at Common Good City Farm, on V Street NW between 2nd and 4th. Or mail to P.O. Box 26030, Washington DC 20001. Or email to

I understand that my daughter/son will be suspended from COMMON GOOD if they are unable to respect other people and consistently do not follow the Common Good Youth Rules. I also understand that if my daughter/son is involved in a physical fight that they will be automatically suspended for one week and may be removed from the program at the discretion of the program directors.

_____Initial Parent or Guardian ______Date

WAIVER AND RELEASE OF LIABILITY

Common Good City Farm, Washington, DC

I, ______(print name), have reviewed, understand, and agree to abide by the Common Good City Farm’s (“Farm”) policies relative to the use of the Farm and the conditions set forth below. I agree to abide by all Farm rules and understand that use of the Farm may be denied if policies or rules are not followed.

By signing below, I acknowledge that I have carefully read this waiver and release and that i fully understand that it is A release of liability.

______

SignatureDate

MUST BE SIGNED BY PARENT OR GUARDIAN IF PARTICIPANT IS UNDER 18 YEARS OF AGE

Moreover, I understand that attendance at or use of the Farm – including the use of tools, equipment, insect control products and fertilizers – or participation in any of the Farm’s activities or programs is a potentially hazardous activity and involves a risk of personal injury, death, property loss, or other damages. I agree expressly to assume and accept all risks and liabilities associated with participation in any of the Farm’s activities or programs, including risks caused by terrain, facilities, soil conditions, temperature, physical exertion, insect/rodent exposure, chemical exposure and the actions of other people.

I understand that my use of the Farm is voluntary and that I do so at my own risk. In consideration of the personal benefits I receive from working in the Farm, I agree on behalf of myself and my guests, heirs, executors, administrators, and assigns fully and forever to waive my right to sue the Farm and each of its affiliates – including, but not limited to its owners, officers, directors, employees, agents, representatives and all others. Moreover, I release and discharge the Farm from any and all claims or demands of any kind, including any and all responsibilities or liability for injuries (including death), penalties, costs, judgments, damages or loss, and all claims or causes of action resulting from the negligent acts or omissions of any of the above mentioned that result from my use of the Farm or in any activities connected with the Farm.

_____Initial Parent or Guardian ______Date

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