We Have a Summer Camp for Ages 3-5

Do you give permission for the participant’s likeness, in photo or video, to be used for Primitive Pursuits or Cornell Cooperative Extension promotional/educational media? *

By signing this form I agree to/give permission for my child to participate in Primitive Pursuits programs of Cornell Cooperative Extension & 4-H Youth Development. I give permission for Cornell Cooperative Extension staff and emergency medical personnel to give me/my child medical treatment if necessary. I give permission for Cornell Cooperative Extension staff to transport my child. I give permission for my/my child’s likeness, in photo or video, to be used for Primitive Pursuits or Cornell Cooperative Extension promotional/educational media. I agree to receive information about future Primitive Pursuits programs. I give permission for my child to use sharp tools and tend fires with adult supervision. I understand that there are inherent dangers in these and other outdoor educational activities and furthermore that I/my child will likely be getting wet, muddy, smelly, and bug bitten. I understand that I must alert Primitive Pursuits staff to any medical conditions or allergies that I/my child may have, and I hereby assert that I have done so to the best of my ability. I hereby apply for myself/my child to participate in Primitive Pursuits to be conducted by the designated Cornell Cooperative Extension Association and acknowledge as follows: I fully understand and acknowledge that there are inherent risks and dangers in my/my child’s participation in the Primitive Pursuits program and my/my child’s participation in said activity or activities and use of any equipment related to such activities may result in injury, illness or death and damage to personal property. I understand other participants, accidents, forces of nature or other causes may cause these risk and dangers and I hereby accept these risk and dangers. I am/my child is in good health and is at or above the minimum age required to participate in this activity and is able to participate in any strenuous physical activity associated therewith. I herewith release, forever discharge and waive any right of recovery or subrogation against the Cornell Cooperative Extension Association listed below, Cornell University and their respective officers, directors, trustees, employees, members and volunteers, from any and all liability whatsoever for any illness or injury, including death or damage to or loss of my personal property that I may sustain while I or my child is participating in this program. This shall be binding on my heirs, successors, assigns, administrators and executors. Any claims or disputes arising out of my/my child's participation in the activity shall first be submitted to arbitration and/or be venued in the Supreme Court of the State of New York of the County where the Association is located, the choice of which shall be at the sole discretion of CCE. I have read the above and by signing it I agree it is my intention to participate/have my child participate in the indicated activity and I understand and accept the risks involved. By signing this form I also assert that:I have read the entire form; I understand all of the terms and conditions stated within; and that I agree to all of them. I am at least twenty-one (21) years of age and I am the legal parent/guardian authorized to sign this document on behalf of any child named herein. *