Emergency Contact Information

Child’s Name:_____________________________________

                        ______________________________________

Date of Birth:_______________________________________

Persons Responsible for pick up:

Phone Numbers:________________________________________

List any known allergies and/or special concerns:

         RELEASE AND WAIVER OF CLAIMS

Dear Art Camp Parent,

         Although every effort is made to protect the safety of your children and their property while attending Art Camp, the open outdoor environment of the Art Barn can include potential dangers (i.e. fire ants, bees, etc). Furthermore, the materials necessary for creating art (i.e. scissors, hammers, etc) can be dangerous. The purpose of these warnings is not to unduly alarm you, but to stress the importance of safety while attending Art Camp and using the facilities of The Green Bell Bed and Barn.

         Because of the inherent potential dangers, both seen and unseen, The Green Bell Bed and Barn has adopted a policy of requiring the parents or guardians of Art Camp participants to assume the risk of personal injury to their child while attending the Art Barn and using the facilities of The Green Bell Bed and Barn and to release and waive any claim or right of action he or she may have against its owner(s), tenants, agents and employees for any loss or damages that arise out of personal injuries.

         Accordingly, the undersigned, on his or her own behalf and on the behalf of his or her assigns and successors in interest, each separately waives, releases, holds harmless and indemnifies The Green Bell Bed and Barn and its owner(s), tenants, agents and employees from any and all claims he or she may have against The Green Bell Bed and Barn or its owner(s), tenants, agents and employees, for personal injury to himself or herself by animals, persons or property or while engaged in Art Barn activities or using the facilities of The Green Bell Bed and Barn.

         Remind your children to be careful and have a good time.

___________________________                   _______________

Signature of parent or guardian                       Date