Fillable Registration Form 2020-2021 (Head2Heart Partners In Education)

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Registration Form 2020-2021 (Head2Heart Partners In Education)

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Head2Heart Partners In Education
Registration Form 2020-2021
Number of children enrolling
______
Price of Program
x $25
Total Annual Registration Due $_____
o Completed Registration forms
o Copy of Transcript if in High School
o $25/Per Student Registration Fee
Parent Signature
Date
Participant Information:
Child’s Name:_________________________Grade:________ DOB:________ Gender: M/F
Child’s Name:_________________________Grade:________ DOB:________ Gender: M/F
Child’s Name:_________________________Grade:________ DOB:________ Gender: M/F
Child’s Name:_________________________Grade:________ DOB:________ Gender: M/F
Child’s Name:_________________________Grade:________ DOB:________ Gender: M/F
Parents/Guardian Information:
Mother Name:____________________________ Phone:____________________________
E-mail: ____________________________________________________________________
Father Name:____________________________ Phone:_____________________________
E-mail: ____________________________________________________________________
Address:___________________________________________________________________
City:_________________________________ Zip Code:_____________________________
Registration Checklist:
________________________________________________________________________
Please initial beside the option you choose below to give your consent:
_____ I give permission for my child’s samples/photos to be shared on H2Hpie's social media
platforms.
_____ I do not give permission for my child’s samples/photos to be shared on H2Hpie's social media
platforms.
________________________________________________________________________
By signing this form you are agreeing to Head2Heart Partners in Education terms to pay your child’s
registration as indicated above. Your child's participation in our program will not become active until
registration fees are received. You are also stating that all information provided in this form is current
and correct.
________________________________________________________________________
M
M
M
M
M
Waiver and Release of Liability
IN CONSIDERATION OF the risk of injury that exists while participating in EDUCATIONAL
PROGRAMMING either virtual or in person (hereinafter the “Activity”); and
IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate
in same;
I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives
(hereinafter collectively, “Releasor,” “I” or “me”, which terms shall include the Releasor’s parents or
guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND
RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising
out of my participation in the Activity; and
I HEREBY release and forever discharge HEAD2HEART PARTNERS IN EDUCATION, located at 72877 Dinah
Shore Dr. #103-414, Rancho Mirage, California 92270, their affiliates, managers, members, agents,
attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (Collectively
“Releasees”), from any physical or psychological injury that I may suffer as a direct result of my
participation in the aforementioned Activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFORMENTIONED ACTIVITY AND I AM PARTICIPATING IN
THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH
PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE BUT ARE NOT LIMITED TO: PHYSICAL,
PSYCHOLOGICAL OR MONITARY LOSS OR HARM. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES
MAY ARISE FROM MY OWN OR OTHERS NEGLIGENCE, MISUNDERSTANDINGS,OR CONDITIONS
RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY
LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME,
OF MY PARTICIPATION IN THIS ACTIVITY.
I FURTHER AGREE, to indemnify, defend and hold harmless the Releasees against any and all claims,
suits or actions of any kind whosoever for liability, damages, compensation or otherwise brought by me
or anyone on my behalf, including attorney’s fees and any related costs.
I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to
act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that
I should require medical care or treatment, I authorize Head2Heart Partners in Education to provide all
emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AED’s,
emergency medical transport, and sharing of medical information with medical personnel. I further
agree to assume all costs involved and agree to be financially responsible for any costs incurred as a
resule of s
uch treatment. I am aware and understand that I should carry my own health insurance.
I FURTHER ACKNOWLEDGE that this Activity may involve interaction with other individuals who may or
may not have been in contact with COVID-19 or any other contractible illness and this may test a
person’s physical and mental limits and may carry with it the potential of death, serious injury, and
property loss. I agree not to participate in the Activity unless I am medically able to and do not pose a
threat to anyone else myself. I also agree to abide by the decision of the Head2Heart Partners in
Education official or agent, regarding my approval to participate in the Activity.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS “WAIVER AND RELEASE” AND FULLY
UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSELY AGREE TO RELEASE AND DISCHARGE
Head2Heart Partners in Education AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS,
ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND
ASSIGNS, FROM AY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP
OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Head2Heart
Partners In Education FOR PERSONAL INJURY OR PROPERTY DAMAGE.
To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is
also for such negligence on the part of Head2Heart Partners in Education, its agents, and employees.
I agree that this Release shall be governed for all purposes by California law, without regard to any
conflict of law principles. This Release supersedes any and all previous oral or written promises or other
agreements.
In the event that any damage to equipment or facilities occurs as a result of my or my families or my
agent’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all
costs associated with any such actions of neglect or recklessness.
THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY
PARTICIPATION IN THE ACTIVITY, DURING THE INITIAL AND ALL SUBSEQUENT EVENTS OF
PARTICIPATION.
THIS AGREEMENT was entered into at arm’s-length, without duress or coercion, and is to be interpreted
as an agreement between two parties of equal bargaining strength. Both Participant,
_______________________________ and Head2Heart Partners in Education agree that this agreement
is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter
or explain the terms of this agreement, but that it will be interpreted based on the language in
accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable
or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be
unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and
effect. If a court should find that any provision of this agreement is invalid or unenforceable, but that by
limiting said provision it would become valid and enforceable, then said provision shall be deemed to be
written, construed and enforced as so limited.
In the event of an emergency, please contact the following person(s) in the order presented:
Emergency Contact Contact Relationship Contact Telephone #
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I, THE UNDERSIGNED PARTICIPANT OR PARENT/GUARDIAN OF UNDERAGED PARTICIPANT, AFFIRM
THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I
CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND IT’S CONTENT AND THAT
THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND
A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.
Participant Information:
Children’s Names: ..............................
Address: .............................................
Responsible Party:
Parent/Guardian Name: ......................
Signature: ............................................
Date: ...................................................
_______________________ Age: ___________________
_______________________ Age: ___________________
_______________________ Age: ___________________
_______________________ Age: ___________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
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Registration Form 2020-2021 (Head2Heart Partners In Education)

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Completed 25 August 2020

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