Kid & Teen GreenJean Workshop: Saturday, April 22, 2017: REGISTRATION FORM

— A DEEP ECOLOGY MONTH PROGRAM OF NEWARK CENTER FOR MEDITATIVE CULTURE —

LOCATION:
Rabbit Hole Urban Farm, 36-38 Rose Terrace, Newark, NJ 07102
RAIN LOCATION:
Rutgers University classroom TBD in Newark
CHECK-IN:
9:45am
PROGRAM DURATION:
10:00am-2:00pm

GUIDELINES TO READ BEFORE REGISTERING (REGISTRATION FORM DIRECTLY BELOW):

IMPORTANT: PLEASE DO NOT RESERVE SPACES, USE THIS FORM ONLY IF ATTENDEES ARE CONFIRMED.

ADULTS SHOULD FILL OUT FORM FOR MINORS:
- Registration deadline is Thursday, April 20, 2017.
- Please fill out one form for each adult attending.
- If you are a guardian/parent bringing up to 5 youth(s), you can use this same form to register the youths.
- To register other adults, you will be prompted by a pop-up window to enter a new form after completing this one.

WHO CAN ATTEND
- Live in urban Greater Newark Area.
- Kids aged 5-11 (kids 5-7 must be chaperoned)
- Teens aged 12-18
- We require at least one adult guardian per 5 youths.

LIABILITY
- This is an informal community program, therefore Newark Center for Meditative Culture (NCMC), 4-H Youth Development Program of Essex/Hudson Counties at Rutgers, Rabbit Hole Urban Farm Newark, and any of the individuals associated with this program will NOT BE HELD RESPONSIBLE for any injuries or loss of personal property.
- Please read the Liability Waiver at the bottom of this Registration Form prior to signing.

TIME
- Please arrive by 9:45am to check-in.
- To get the most out of the program, all participants are encouraged to stay for the duration of the workshop (10:00am - 2:00pm) and expected to stay no less than three hours. If you anticipate a late arrival or leaving early please fill in this information on the form as indicated.

DONATIONS
- This workshop is free, though we welcome donations. Your generosity helps to gift the teachers and cover any expenses incurred for this program.

INFORMATION
- You will hear from NCMC a few days before the workshop with final details.
- You are also welcome to ask us any questions you might have beforehand. Email below.
- We do not share any of your personal information.

CANCELLATION
- We ask that you please cancel if for some reason you cannot attend. This helps us with our plans for food, other provisions, and concern about your whereabouts!

EMAIL: Contact us at info@newarkmeditation.org.

Registration Form
1) First Name (adult: guardian/parent/chaperone) *
Your answer
2) Last Name *
Your answer
3) Are you 18 years of age or older? *
4) Email Address *
If you do not have an email address, type in "none"
Your answer
5) Phone Number
REQUIRED ONLY IF YOU DO NOT HAVE AN EMAIL ADDRESS. Include area code.
Your answer
6) Address (optional)
Street, City, State, Zip Code
Your answer
7) For which Workshop are you registering the youth/s? *
Required
8) Please give relationship to kids/teens you are registering: *
Required
9) Please give full name(s), age(s), and youth organization/school represented (if any) for all participating youths that you are registering. *
One adult can register up to 5 youths. Please list with full names and ages.
Your answer
10) It is required that an adult be able to stay with the participants aged 5-7 (no more than 5 per adult). Do you agree to attending with the participant? *
11) To get the most out of the program, all participants are encouraged to stay for the duration of the workshop (10:00am - 2:00pm) and expected to stay at least 3 hours. If you anticipate a late arrival or leaving early please put those times below. *
Your answer
12) We plan to have a GreenJean Party from 2:00-2:30pm. Will participants want to join this as well? *
13) How many lunches do you/your group require? IMPORTANT: Also list any basic food restrictions such as gluten-free, citrus, etc. and how many require this restricted menu. *
(Example:.2 gluten free, 1 citrus free, etc.) One lunch per person! You are also welcome to bring your own bag lunch if you prefer or if you have food allergies such as to nuts that we are unable to accommodate. We'll also prepare a healthy snack together so need to understand restrictions.
Your answer
14) Would you like to subscribe to receive news about NCMC programs? *
We generally email just once a week and most updates pertain to meditation programs.
15) Liability Waiver
ACKNOWLEDGEMENT OF RISKS: I waive and release any and all claims against Newark Center for Meditative Culture (NCMC), 4-H Youth Development Program of Essex/Hudson Counties at Rutgers, Rabbit Hole Urban Farm Newark, and any of the individuals associated with this program “Kid & Teen GreenJean Workshop” to be held on Saturday, April 22nd, 2017 from approximately 10:00am to 2:00pm for any injury or illness (mental or physical) which may directly or indirectly result from my participation in this above mentioned program. The risks include, but are not limited to, those caused by terrain, facilities, meals, equipment, lack of hydration, temperature, weather, physical condition of individuals, vehicular traffic, actions of other people including, but not limited to, instructors, participants, volunteers and, spectators, event officials and event monitors, and/or producers of the event, as well as negligence or carelessness of any of these people. These risks are not only inherent to individuals, but are also present for volunteers. I state that I, and my wards if any, am/are in proper condition to participate in the event. NCMC reserves the right to refuse any entry.

PARENT GUARDIAN WAIVER FOR MINORS (aged 5 years through 18 years old): The undersigned parent and natural guardian, legal guardian, or chaperone does hereby represent that he/she is, in fact, acting in such capacity and agrees to release, save and hold harmless and indemnify each and all of the Entities and Persons from all liability, loss, cost, claim or damage whatsoever which may be imposed upon said Entities and Persons because of any defect in or lack of such capacity to so act.

CHAPERONES: Each adult chaperoning youths agrees that they have received explicit permission from the parent or legal guardian of each youth with the parent's or legal guardian's understanding and approval of the above terms of liability.

ASSUMPTION OF RISKS: By checking the box below and adding my electronic signature, I acknowledge that I have read the above Liability Waiver statement and I understand its content. I hereby assume all risks of participating and/or volunteering in the above mentioned program and take full responsibility for my own and my minor-aged ward’s (if any) personal safety and personal property while attending an NCMC event.

*
Required
16) Consent to Media *
I understand that at this event or other NCMC activities, I or my wards may be photographed. Do you allow your/your wards photo, video, or film likeness to be used for any legitimate promotional purpose by the Event holders, producers, sponsors, organizers and/or assigns?
17) Electronic Signature *
Full Name
Your answer
18) Comments, questions, or things you think we might need or want to know.
Your answer
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