If you would like this information in an alternatitve format, or would like help in completing this form, please contact us at [email protected].

1. Consent to attend Huckleberries

• I consent to my child attending Huckleberries Nurture Farm.

• I am aware that outdoor activities have an inherent risk of personal injury, and I have understood the nature of the activities my child will be undertaking.

• I accept the risk involved and consent to them participating.

• I consent to Huckleberries holding the information provided below securely on file and to any information collated about my child’s progress whilst they are at Huckleberries.

• In the case of videos and photographs I consent to these being used as I have indicated below.

Childs name
Your name	Contact Email
School name	School year 12345678DofE
Emergency contact 1 Name	Emergency contact 1 Tel.
Emergency contact 2 Name	Emergency contact 2 Tel.

I consent to an overview of my childs needs being provided to Huckleberries by their school. We will use this information to help meet their needs and monitor progress
yesno

2. Allergies and Medical Information

Please complete the form below identifying allergies and relevant medical conditions.

My child has allergies

NoneMildModerateAnaphalaxis reaction

My child has other medical conditions

yesno

I consent to my child receiving urgent medical treatment in the case of an emergency, including anaesthetics

yesno

3. Use of photographs and videos

Data protection rules require us to seek your consent for some of the ways that we use images and information about your child. Please indicate your consent to us using images, videos or quotes in the ways listed below. If you change your mind you can update this form by contacting Huckleberries at [email protected].

I am happy for photographs of my child to be taken, and given to my child and other children in their group as a keepsake when they leave.

yesno

I am happy for photographs or videos of my child to be used on Huckleberries website and own social media, for example Facebook & Instagram. No names would be included.

yesno

I am happy for photographs of my child to be used in the media, for example in print and on-line digital media, advertising or newspapers supporting or promoting Huckleberries work, or by funding bodies who support some of Huckleberries work. No names would be included.

yesno

I am happy for photos or videos of my child that do not show the child’s full face e.g. back of head, face cropped or blurred, making it difficult to identify the child, to be used on Huckleberries web-site, our own social media, promotional materials, digital media, grant funding applications/reporting. No names would be included.

yesno

I am happy for quotes or feedback from me/my child to be included in promotional materials, grant applications/reports, and Huckleberries website or social media. No names would be included.

yesno

4. Assumption of risk and waiver of liability relating to activities, COVID-19 and other diseases

Please read carefully the following waiver of liability and sign to acknowledge the risk, to enable your child to attend Huckleberries Nurture Farm.

COVID-19

Huckleberries Nurture Farm CIC (“Huckleberries”) has put in place preventative measures to reduce the spread of COVID-19. However, Huckleberries cannot guarantee that you or your child(ren) will not become infected with COVID-19, and attending Huckleberries could increase your risk and your child’s risk of contracting COVID-19.

EXPOSURE TO MICRO-ORGANISMS CARRIED BY ANIMALS

Whilst it is uncommon for members of the public to become ill after visiting farms, in the past in the UK there have been a small number of cases of ill-health caused by exposure to micro-organisms that can be carried by animals (such as E.Coli, Cryptosporidium, Leptospirosis (weils disease), Borreliosis (lymes disease), or tick borne encephalitis (TBE). Whilst Huckleberries has put in place preventative measures through operational practices and infection control measures, and we discuss the importance of animal hygiene and hand washing with your child, Huckleberries cannot guarantee that your child will not become infected with these micro-organisms whilst attending Huckleberries.

OUTDOOR ACTIVITIES

Whilst at Huckleberries your child will participate in outdoor activities such as fire lighting, outdoor cooking, walks, tree climbing, use small tools, and care for the animals. These activities carry a risk of personal injury, illness, permanent disability, and death. Whilst Huckleberries has put in place preventative measures through a risk assessment, operational practices and control measures, and we discuss with your child how to stay safe, it is important that you are aware of and accept this risk.

By submitting this consent form, I acknowledge the inherent risk associated with contact with animals, outdoor activities, and the contagious nature of COVID-19, and voluntarily assume the risk that my child and I may be exposed by attending Huckleberries, and that such activity, exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of injury or becoming exposed to or infected by COVID-19, or micro-organisms carried by animals at Huckleberries may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Huckleberries employees, practitioners, volunteers, and other programme participants and their families.

I understand and voluntarily agree to assume all of the foregoing risks, and that other than in the case of death or personal injury caused by the negligence of Huckleberries, its employees, agents, and/or representatives, I acknowledge and accept that Huckleberries, its employees, agents, and representatives will not accept any liability for (including, but not limited to) any injury to my child or myself (including, but not limited to, personal injury, disability, and death), illness, damages, loss, claims, actions, demands, costs and/or expenses, of any kind, that I or my child may experience or incur in connection with my child’s attendance at Huckleberries and/or otherwise arising out of my child’s attendance at Huckleberries (“Claims”).

On my behalf, and on behalf of my child, I hereby waive, release, covenant not to sue, discharge, and hold harmless Huckleberries, its employees, agents, and representatives, of and from all or any Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.

I understand and agree that this waiver and release to the extent permitted by law includes any Claims based on the actions, omissions, or negligence of Huckleberries, its employees, agents, and representatives, whether injury or infection occurs before, during, or after participation in any Huckleberries programme.

I accept the terms of this agreement