• 2019 Progressive Agriculture Safety Day® Release & Consent Form

    Note: If you do not give permission for all or part of items 2, 3, or 4, please answer no to these statements in this form and someone from the Chamber will contact you with the paper release & consent form so that you may mark through and initial the statement(s) that you do not agree to. However, if you do not agree to item 1, your child cannot attend the Safety Day.
    Name Block - Simple
    Please insert participant's first and last name.
    Address Block - US
    1. I give my permission for the child listed above to attend the Progressive Agriculture Safety Day®. I understand that one of the purposes of the Progressive Agriculture Safety Day® is to teach participants to stay safe on farms, ranches and at home with a variety of age-appropriate lessons. During the Safety Day, safety barriers will be in place, safety rules will be enforced, and participants will be closely supervised by Safety Day instructors and group leaders. However, I acknowledge that there is the possibility of accidents. I release the coordinators, instructors, volunteers, sponsors, the Progressive Agriculture Foundation, and the Progressive Agriculture Safety Day® program from all claims, in the event of injury to my child, unless the injury is the result of gross negligence or willful misconduct on the part of these parties. *
    2. First aid will be available at the Safety Day and medical and/or hospital care will be provided in case of serious illness or injury. I understand that if serious illness or injury occurs the emergency contact(s) listed in the registration form will be notified. If it is impossible to reach the emergency contact(s), I give permission for emergency treatment as recommended by the attending physician. *
    3. I give my permission for photographs, audio, and video to be taken of my child while engaged in Safety Day activities and for these images to be used to promote safety in the media, social media, on websites, and in promotional materials. *
    4. I understand that my child might be asked to complete a written knowledge survey before and after the Safety Day to help evaluate the effectiveness of the Progressive Agriculture Safety Day® program. Participation is voluntary, and my child may choose not to participate. I give permission for my child to participate in these evaluations. *
    Please insert your digital signature including first and last name.
    Please insert your email address.
    Please insert your best contact phone number, including area code.
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