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Email Address *

First Name

Last Name

Address

City

State/Province

Zip Code

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Agreements

I do hereby release Fields to Families and all of its supporting farms, organizations and agencies, and all of its directors, officers, agents, staff and volunteers from any and all liability for any and all damages or injuries that may result to my person or property as a result of my role as a volunteer.

Agreements

I hereby grant permission to Fields to Families representatives, to take and use: photographs and/or digital images of me for use in news releases and/or educational materials.I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negatives,prints, digital reproductions shall be the property of Fields to Families.

Parent/Guardian Signature

Date

Agreements *

By completing and submitting this application, I affirm that the facts set forth are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal

Minor Registration & Waver