Multiple Children in Brigade?

Please only register one child at a time using this registration form.

Quantity
Price
Total
Early Bird Building Leaders Program Membership

October 2019-April 2020 Early Bird Discount

X
$
79.00=
$
0
Name of Last Brigade Group

Brigader Contact Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

Parent/Guardian Information: This is used as emergency contact information and to better understand the families we serve. Please list information that is different than that which is listed in the Child information area above.

Parent/Guardian 1 Name
Parent/Guardian 1 Relationship to Brigade Member
Parent/Guardian 1 Address
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Home Phone
Parent/Guardian 1 Email
Parent/Guardian 1 Employer
Parent/Guardian 2 Name
Parent/Guardian 2 Relationship to Brigade Member
Parent/Guardian 2 Address
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Home Phone
Parent/Guardian 2 Email
Parent/Guardian 2 Employer

Demographic Information

By completing the following information, The Brigade is better able to understand the population we serve. All information in this application will be kept confidential.

Date of Birth
Annual Household Income
Number in Household
Ethnicity
  • Hispanic
  • Hmong
How did you hear about the Brigade?
  • Friend
  • Family Member/Neighbor
  • Ad in newspaper/magazine
  • Social Media
  • School Field Trip
  • Website
  • Other

RELEASE OF LIABILITY AND

ASSUMPTION OF RISK AGREEMENT

 

Acknowledgement of Risks:

I acknowledge that there is inherent risk of injury in the services provided by the Boys’ & Girls’ Brigade.  I hereby assume full responsibility and risk of injury, death, property damage, any loss or liability and any cost that may be incurred as a result of participation in Brigade sanctioned activities.  I assume the risks for all Boys’ & Girls’ Brigade activity at any location and any ensuing transportation involved.  I understand that camp outings provide an increased level of physical and emotional risks as I have read below and I agree to assume these risks.

 

Insurance:

I understand it is my responsibility to provide for my child’s own accident and health coverage while participating in Boys’ & Girls’ Brigade programs and I further understand that the Boys’ & Girls’ Brigade does not provide this coverage.

 

Photograph Permission:

I give permission for the Boys’ & Girls’ Brigade to use, without limit or obligation, photographs, film footage or tape recordings which may include my child’s image (including nametag identification) or voice for purposes of publicity, promotions and public relations. These images may appear in any brochure, magazine, film, social media (including but not limited to Facebook) or other media.

 

Property Loss:

I understand that the Boys’ & Girls’ Brigade is not responsible for personal property lost, damaged or stolen while using Boys’ & Girls’ Brigade facilities or participating in Boys’ & Girls’ Brigade programs.

 

Medical Treatment:

In the event that I cannot respond, I give permission for emergency medical, surgical and hospital treatment and procedures to be performed by a licensed physician, nurse or hospital when deemed immediately necessary or advisable by a physician to safeguard my child’s health.

 

Release from Liability:

I hereby agree to release the Boys’ & Girls’ Brigade, its employees, volunteers, agents, and independent contractors from any and all responsibility and liability of any nature, including claims for injury, illness, death, loss or damage resulting from my child’s participation in any Boys’ & Girls’ Brigade activity. 

 

Awareness of Risks for Camp Outings

 

Camp outings are a special part of the Boys’ & Girls’ Brigade program.  The elements that make camp a unique experience, such as being outdoors, in and around water and traveling by bus, automobile and powerboat, can cause loss or damage to equipment, injury, illness and even death.  We want all participants to know in advance what to expect and what some of the potential risks are by participating in camp outings. 

 

The following describes some, but not all, of the activities with risks:  Activities may include games involving running, group initiative problems and other rigorous physical adventure activities.  Participants may be outdoors for periods of time exposed to wind, rain, snow, sun and other natural elements.  If doing a ropes, climbing or challenge course, participants may be climbing trees or walking on cables and logs which are suspended in the air.  If riding in powerboats or boats not under power there may be exposure to natural conditions for prolonged periods of time, including the possibility of drowning.  Camps also expose participants to fire and wildlife, to potentially slippery paths and to bunk beds from which participants could fall. 

 

I have read and understand this document and I agree with the terms in their entirety.

Please check the 2019 box if you agree to the above terms. You must be the registering Brigader age 18 or above, or be the legal guardian of the Brigader being registered in order to provide this consent.*
  • 2019

Payment Information

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$
Name on Card*
Card Number*
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