Katherine Grace Bond

Students: Grade: ____________ Birth date: ________________

Parent/Guardian Names (if under 18): ______________________________________________________________

Address: ______________________________________________________

Phone: _______________________ cell: ____________________________

E-mail: ________________________________________________________

Emergency Contact: _____________________________________________

Phone: __________________________ cell: _________________________

Insurance Company: _____________________ Group #: _______________
Policy #: _______________________________

MD: ______________________________ Phone: ______________________

Allergies: ______________________________________________________

Medical Conditions: _____________________________________________

Medications needed during camp: __________________________________

Other pertinent information: ______________________________________________________________

Name of Camp or Workshop: _____________________________________

How did you hear about the workshop?_____________________________

If under 18:

I give my permission for my child, ____________________ to attend a writing workshop with Katherine Grace Bond. I know that I will be fully informed of each day’s location(s) and I give my permission for Katherine Grace Bond to drive my child to said locations if necessary.

I understand that Katherine Bond, leader, will make every reasonable effort to provide a safe environment, although I am fully aware of the special dangers and risks inherent in participating in the activity. These could include physical injury, death and other consequences arising or resulting from the activity.

In the event of an accident or illness, I understand that every reasonable effort will be made to contact me, the parent immediately. However, if I am unavailable, I authorize Katherine or Andrew Bond to secure emergency medical care as needed.

I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, whether caused by negligence of releasees or otherwise.

_____________________________________________________________
(Parent signature)

 Adult participants:

I am fully aware of the risks involved and hazards connected with Writing Camps or Workshops, and I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, whether caused by the negligence of releasees or otherwise.

I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, whether caused by negligence of releasees or otherwise.

_____________________________________________________________
(Signature)

Please send check, payable to Katherine Grace Bond, to:

Katherine Grace Bond
c/o Dawn Pontious
22721 87^th Ave. SE
Woodinville, WA  98077

_______$50 deposit holds your spot.  Payment in full (amt.________________) due 2 weeks before workshop.