HQ STAFFORD – Week 1: Rising 3rd, 4th, 5th, 6th, 7th, & 8th Graders | June 1 -June 5

Basic Contact Information

At the end of this process, you will have completed all health and waiver paperwork required for your child to attend our summer camp. Be aware it may take a few minutes.

Parent/Guardian Name*

First Last

Alternate Parent/Guardian Name*

Applicable if you have a spouse that will occasionally do pickup/drop off

First Last

Email*

Enter Email Confirm Email

Parent / Guardian Phone*

Camper Home Address*

Street Address Address Line 2 City State ZIP Code

Friends of the Rappahannock Waiver

Crow's Nest Research Center Waiver

As part of our partnership with Crow's Nest Research Center, both their waiver and FOR's waiver have to be signed. (We know it's repetitive so thank you for reading it and completing all the forms in advance!)

I, ___________________________, (the “Undersigned”) hereby acknowledge that I have voluntarily requested to access and to participate in certain activities, including, without limitation, participating in research projects, accessing and observing all or portions of the Property described below and visiting or otherwise participating in any event or function and any other activity whatsoever in connection with the Crow’s Nest Research Center (collectively, the “Activities”) on the property located at 400 Marlborough Point Road, Stafford, VA (Property ID 49C-1-1-7), hereto (the “Property”), owned by 400 Marlborough LLC (the “Owner”) and operated by Crow’s Nest Research Center (“CNRC”), a non-profit organization.*

Participant Name

First Last

Please read the following carefully*

IN CONSIDERATION for being permitted to enter upon the Property upon which the Activities are conducted, and for being permitted to participate in or observe Activities or otherwise use the Property, the Undersigned on behalf of myself, my heirs, personal representatives and assigns, agree to
the provisions set forth below:

1. The Undersigned hereby voluntarily, knowingly and unconditionally releases, waives, discharges and covenants not to sue, make a claim against the person or persons or property or otherwise prosecute or file any suit or other action against the Owner, CNRC, or any affiliate organization, officers, directors, managers, members, agents and/or employees of the Owner or CNRC (hereinafter collectively referred to herein as “Releasee”), for any claim, loss, cost, damage or liability on account of damage to the property of or injury to the person or death of the Undersigned, whether caused from the passive or active negligence of Releasee or otherwise.

2. The Undersigned hereby agrees to indemnify, defend and hold Releasee harmless from and against any claim, loss, liability, damage or cost that Releasee may incur due to the presence of or any act or any omission of the Undersigned while the Undersigned accesses, participates in or observes any Activities on the Property, whether caused by the passive or active negligence of Releasee or otherwise.

3. The Undersigned expressly agrees that this Release, Waiver and Indemnity Agreement is intended to be as broad as is permitted by the laws of the Commonwealth of Virginia. The Undersigned further agrees that if any provision of this Release, Waiver and Indemnity Agreement is held to be invalid, nevertheless, the balance of this Release, Waiver and Indemnity Agreement shall remain enforceable and continue in full force and effect.

4. The Undersigned warrants that the covenants and agreements herein are enforceable, true and correct and understands that Owner and CNRC have relied on the same as a condition to giving the Undersigned permission to access the Property and participate in and/or observe Activities on the Property.

5. The Undersigned agrees that if he or she damages any of the Property, including the improvements thereon, the Undersigned will pay as damages to the Owner and CNRC, the fair market
value thereof as of the date of damage or loss.

6. The Undersigned acknowledges that nothing herein is intended to grant a license or right permitting the Undersigned to access the Property or otherwise engage in activities. Owner and CNRC
reserve the right to require a representative accompany the Undersigned at all times.

THE UNDERSIGNED HAS CAREFULLY READ AND FULLY UNDERSTANDS THE COVENANT NOT TO SUE CONTAINED HEREIN AND WITH FULL KNOWLEDGE OF THE TERMS HERE OF VOLUNTARILY AND UNCONDITIONALLY SIGNS THIS RELEASE, WAIVER AND LIABILITY AGREEMENT.

Age of Participant*

Please enter a number from 5 to 20.

Date*

Parent/Guardian Name*

First Last

Parent/Guardian Signature*

Address*

Street Address City State ZIP Code

Phone*

Camper Information

Camper Name*

First Nickname (if different from First Name) Last

Gender*

Rising Grade Level*

This is the grade level the camper will be attending Fall 2026

Camper Date of Birth*

Medical History*

Any surgeries or essential medical details we should need be aware of.

Allergies*

First Aid*

This camp is outside and sometimes little injuries do occur such as bee stings or scraped knees. This is a precaution and parents are always called when an incident occurs.

Is there anything else we should know about your camper?

Will they have siblings or friends in camp with them? Are they deadly afraid of spiders/ snakes? Do they have a favorite thing that helps them make friends quickly?

Emergency Contact

This is the individual who should be called if your camper is sick, injured, etc.

Emergency Contact Name*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

What is the Emergency Contact's Relationship to the Camper?

Camper Pick Up

For anyone who is not listed as the Parent/Guardian or Alternate Parent/Guardian who will be picking up your camper.

Name

First Last

Phone

Relationship

What is the Relationship to the Camper?

Parent Guardian Electronic Signature*

I am the parent or legal guardian of the Volunteer/Participant. I have read this form and understand and acknowledge the risks and liability. I understand that by signing this form, I am giving up legal rights and remedies.

How did you hear about this camp?*

Protected: HQ STAFFORD – Week 1: Rising 3rd, 4th, 5th, 6th, 7th, & 8th Graders | June 1 -June 5

Password Protected

Basic Contact Information

Friends of the Rappahannock Waiver

Crow's Nest Research Center Waiver

Camper Information

Emergency Contact

Camper Pick Up

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