Newark Center for Meditative Culture: Teen EcoWarriors & EcoProtectors Clark's Pond Clean-up & Activities in Branch Brook Park: Sunday, March 26, 2017: REGISTRATION FORM

MEETUP: Southeast side of Clark’s Pond off of Branch Brook Park Dr. Easy parking. Walking distance from Bloomfield Ave Light Rail Station. Details will be emailed to you closer to the event.
Check-in 10:45am
Program duration 11:00am-1:00pm:
11:00am-11:45pm @1w/nature tai-chi-gong • Kazi/The Medicine Lifestyle (Southwest side of Pond)
12:00pm-12:45pm Clark’s Pond Clean-up • Arelís Hernandez/Newark Center for Meditative Culture (East side of Pond)
12:45pm-1:00pm Urban deep-eco talk • Andrea Lee/Newark Center for Meditative Culture
Picnic after, weather providing provided by Rabbit Hole Urban Farm Newark (Southwest side of Pond)



- Registration deadline is Thursday, March 23, 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.

- Live in urban Greater Newark Area.
- Youths aged through 17 years old must be accompanied by adults.
- We require one adult guardian per 5 youths.

-This is an informal community program, therefore Newark Center for Meditative Culture (NCMC), The Medicine Lifestyle, Rabbit Hole Urban Farm Newark, Branch Brook Park, the Essex County Park system, 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.

- This program is free. We do welcome donations from adults in order to support our teachers and venue providers.
- Cash donations can be given either at check-in or check-out of program.
- Your generosity is how we keep our programs happening so please consider a "pay it forward" donation no matter how small it's big!

- 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.

- 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

Registration Form
1) First Name (adult)
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
Your answer
6) Address (optional)
Street, City, State, Zip Code
Your answer
7) Please give full name, age, and youth organization/school represented (if any) for youths who you will be chaperoning. (If none, write "none" on first line.)
One adult can bring up to 5 youths. Please list with full names and ages.
Your answer
8) How many lunches do you/your group require?
NOTE: If weather is too cool, we will not have the picnic. One lunch per person! Vegetarian sandwiches (some with gluten-free bread) will be provided. You are also welcome to bring your own bag lunch if you prefer or if you have other food restrictions.
Your answer
9) 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.
10) Liability Waiver
ACKNOWLEDGEMENT OF RISKS: I waive and release any and all claims against Newark Center for Meditative Culture (NCMC), The Medicine Lifestyle, Rabbit Hole Urban Farm Newark, Branch Brook Park, the Essex County Park system, and any of the individuals associated with this program “Teen EcoWarriors & EcoProtectors Clark's Pond Clean-up & Activities in Branch Brook Park” to be held on Sunday, March 26th, 2017 from approximately 11:00am to 1:00pm 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 0 years through 17 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.

11) 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?
12) Electronic Signature
Full Name
Your answer
13) Comments, questions, or things you think we might need or want to know.
Your answer
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