Release & Emergency Info

Participant's Name *

First Name

Last Name

Parent or Guardian's Name

First Name

Last Name

Phone *

(###)

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Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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I have read and agree to the terms set forth in the clearly provided Release of Liability & Assumption of Risk Agreement as well as the Financial Policy. *

I also agree that my registration information constitutes a legally valid electronic signature, as set forth in the VT UET & federal ESIGN acts.

Yes, I agree to release Milldale Farm Center for Wellness and all affiliated entities of all liability and assume the risk of participating in any service, event, retreat, or accommodation.