T-Shirt size

Please indicate any/all disabilities, medical, emotional or behavioral conditions that might limit and/or influence the youth’s involvement in daily activities:

Please indicate any/all youth's food related allergies

General Program Policies

For safety and security, all program participants must be dropped off and picked up by a registered parent/guardian/approved adult (as identified on the registration form). Photo I.D. is required for anyone picking up any program participant from the program location.

For safety, shirts with sleeves (no tank tops or spaghetti straps) and closed-toe shoes with socks are required. Long pants or trousers are recommended and, otherwise, comfortable, casual clothes are acceptable.

Portable electronic devices (iPods, iPads, tablets, etc.) are not allowed. Cellular phones are allowed but may not be used during program hours.

A healthy snack will be provided. Food allergies must be disclosed in writing in the registration document. Personal water bottles are recommended. Refrigeration is available for lunches. Lunches requiring refrigeration are not recommended for field-trip days.

Consent, Release, and Waiver of Liability

Please read this form carefully. Be aware that by signing this form, you are assuming all risk and legal liability of participation and hereby waive and release all claims for injuries, damages or loss which you or your minor child/ward (“child”) might sustain in connection with any Humane Society for Southwest Washington (“HSSW”) sponsored program activities.

Acknowledgement and Assumption of Risk

I give permission for my child to participate in HSSW’s youth programs. I am duly aware of the risks and hazards that may arise through participating in these programs and assume the risk of any expenses and liabilities which may be incurred in the event of an accident, illness or other incapacity. I understand that these activities may include exposure to and interaction with animals and the potential for injuries including, but not limited to, bites and scratches. As the parent/legal guardian of the named child, I assume all risks and hazards which may directly or indirectly arise out of or be connected to my child’s involvement with youth program activities at HSSW facilities as well as any related field trips or off-site activities. I verify that I have indicated any and all allergies, disabilities, medical, emotional or behavioral conditions that might limit and/or influence my child’s involvement in program activities. If I have any questions about the program activities, or the nature, risks or hazards thereof, I will contact the Education Program Coordinator and resolve my concerns to my satisfaction. I am aware that the activities in which my child is voluntarily engaging require that he/she be physically, mentally, and emotionally fit and able to participate. I recognize that it is my sole responsibility to accurately and honestly assess the physical, mental, and emotional fitness of my child. I further state that I am aware of all inherent dangers of participation and the risks associated with my child’s participation and I understand, accept and assume those hazards and risks, and waive all claims I or my child may have against HSSW and others as set forth below.

Hours of Participation

I acknowledge that HSSW does not provide additional child care services before or after program hours. I acknowledge that failure to pick up my child within 10 minutes of the program’s end or dropping off earlier than 10 minutes prior to the program’s start will result in an additional $20 per hour fee (charged in 15-minute increments) for pre- or post-activity care.

Release of Liability

I have read, understand, and agree to the provisions of this Consent, Release and Wavier of Liability. I am aware of the risks involved and consent to my child taking part in the activities at HSSW. I acknowledge that my child’s participation in activities with HSSW is voluntary and that he/she will take due care during such participation. I hereby release and discharge, and agree to indemnify and hold harmless, the officers, directors, members, agents, employees and volunteers of HSSW against all claims, demands, and causes of action whatsoever, relating to injury, disability, death or other harm, to any person or property or both, which may be connected to or arise out of my child’s participation in these activities. I understand this means that, among other things, I am hereby giving up my right to sue for any such losses, damages, injury or costs that I or my child may incur. After careful deliberation, I voluntarily give my consent and agree to this Consent, Volunteer Release and Wavier of Liability. This Release will be binding and enforceable against me, my child and our respective personal representatives, estates, successors and assigns with respect to my child’s participation in the HSSW youth programs.

Medical Release

In the event of an emergency occurring at HSSW affecting my child during program activities, my child will be taken to the nearest emergency medical facility. I acknowledge that, should a medical emergency occur, HSSW program staff will contact the parent/guardian identified on the registration form as soon as possible. In the case of an emergency and if I am unable to be reached within a reasonable time period considering the extent of injury, I grant permission for HSSW staff and/or volunteers to seek professional medical treatment for my child at my expense.

I acknowledge HSSW program staff and volunteers CANNOT dispense any medication. I agree that I must make arrangements to administer and/or dispense any medication my child needs. If my child requires an aide due to special needs, then either I or an adult helper I select will be present to assist my child during program activities.

Food Allergies Disclosure

I certify that, in registering my child for this program, I have listed any food related allergies my child has. If no foods are listed, I certify that my child has no food related allergies.

Media Release

By signing below, I further irrevocably grant HSSW the unrestricted right to use the likeness, photos, video images and voice recording of my child for any purpose (including website, Facebook, Instagram and print) for promotion, advertising or other purposes at any time now or in the future. Neither I nor my child will receive any consideration, and I agree no monetary or other claims will be made against HSSW by me or on behalf of my child for the use of said photograph(s) and/or video.