Name *

First Name

Last Name

Phone *

(###)

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Are you allergic to bees? *

Yes

No

Not sure

Emergency Contact Phone *

(###)

###

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Participant Waiver *

I hereby agree to participate as a participant on the Victory Garden Urban Farm and perform activities including, but not limited to, digging, lifting, carrying, mulching and moving soil. I understand that my participation in this activity with Victory Garden Initiative is completely voluntary.

I understand that due to the physical activities, some of which are strenuous, there is a risk that I may be injured while participating in the project. I hereby acknowledge that should I sustain an injury or illness in connection with my participation. I will not be afforded any form of medical insurance or workers’ compensation benefits. I fully understand the type of activities which will be taking place during my activities on the farm and agree with and consent to all of the terms for participation set forth and presented to me at the time of my orientation.

I agree to release and forever discharge Victory Garden Initiative, their officers, agents, employees and representatives from any and all liability claims or demands that might arise out of or in connection with: 1) any accident, illness, injury or other consequences or event arising from my participation in this project, or 2) any cause beyond the control of Victory Garden Initiative including, but not limited to, natural disasters, civil disturbances, and weather.

Media Release

I do hereby grant and convey unto Victory Garden Initiative all rights, title, and interest in any and all photographic images and video or audio recording made by Victory Garden Initiative during my participation with VGI, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

Release for a Minor

I do hereby release Victory Garden Initiative of any and all potential injuries to my child or the child under my care during their visit to Victory Garden Initiative.

Media release for a minor

I do hereby grant and convey unto Victory Garden Initiative all rights, title, and interest in any and all photographic images and video or audio recording of my child or the child under my care made by Victory Garden Initiative during participation with VGI, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.