Heritage Landing Winter Camp Participant Information and Registration

Child's Name

Full Name *

T shirt size (XS,S,M,L) *

Grade *

Child 2 (If Applicable)

Full Name

T shirt size (XS,S,M,L)

Grade

Child 3 (If Applicable)

Full Name

T shirt size (XS,S,M,L)

Grade

What Elementary School does your Child/ren Attend? *

Early Bird Special Expires 12/1 Coupon Code: WINTER23

Winter Camp December 26th-29th

Select all that apply:

December 26th-29th $250

December 26th-29th Second Child

December 26th-29th Third Child

Winter Camp January 2nd-5th

Select all that apply:

January 2nd - 5th $250

January 2nd - 5th Second Child

January 2nd - 5th Third Child

Please don't forget to enter the coupon code below to get your. EARLY BIRD DISCOUNT (EXPIRED)

Early Bird Special Expires 12/1 Coupon Code: WINTER23 (EXPIRED)

Current Total:

$0.00

Adult Primary Contact 1

Relationship to Participants: *

Parent

Guardian

Other Other

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email *

Adult Primary Contact 2

Relationship to Participants:

Parent

Guardian

Other Other

First Name

Last Name

Address 1

Address 2

City

State

Zip

Phone

Email

Emergency Contact

Emergency Contact 1 *

Phone *

Emergency Contact 2

Phone

Primary Care Pediatric Contact

Doctor's Name *

Phone *

Does your child have any allergies? (N/A for none)

Sports and Arts Participation Waiver

Parent or legal guardian must sign below before acceptance into program:

As parent/legal guardian of the child named herein, I hereby represent that the child has been deemed physically fit by his/her pediatrician to participate in Sports instruction. I understand that there are inherent risks in participating in this athletic program.

I hereby accept responsibility for and agree to pay any and all costs of medical treatment resulting from any injury suffered by my child as a result of his/her participation in all physical activities with Sports & Arts.

I understand that all enrollments are final and no refunds will be issued once payment is made. However, if there is an unforseen emergency funds can be prorated to another future Sports-and-Arts program.

I further agree to indemnify and hold harmless Sports & Arts LLC and any of their coaches from any and all liability, damage, cost or expense arising out of my child's participation of every kind and nature.

In the event that I cannot be reached in an emergency, I hereby give permission for the care to be administered by Sports & Arts staff, EMT, physician / staff of hospital or any other qualified individual to provide medical treatment deemed necessary for my child.

I give permission to communicate with me via text and email and to take pictures and/or videos of my child for Sports and Arts website and marketing purposes.

Please print name below: *

Please Sign Below: *

clear

Sports and Arts Covid Waiver

Parent or legal guardian must sign below before acceptance into program: I agree to release Sports and Arts LLC and its Employees from any and all liability for the unintentional exposure or harm due to the Coronavirus (COVID-19). Furthermore, I understand that my name and contact information might be shared with the state health department if a client or person at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

Print Name *

Signature *

clear

HERITAGE LANDING Summer Camp Waiver

HERITAGE LANDING COMMUNITY DEVELOPMENT DISTRICT RESIDENT FACILITY USE WAIVER AND RELEASE

READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS WAIVER AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS AND WILL LIMIT OR ELIMINATE YOUR ABILITY TO BRING A FUTURE LAWSUIT.

In consideration for the ability to use the Heritage Landing Community Development District’s (the “District”) recreation improvements for the purpose of participating in a Sports and Arts, LLC Kids Summer Camp (“Activity”), I, ____________________________________, (print name below) *

on behalf of myself, my personal representatives, my minor children and my heirs hereby voluntarily agree to indemnify, defend, release, hold harmless, and forever discharge the District, and its present, former, and future supervisors, staff, officers, employees, representatives, agents, and contractors (including but not limited to Vesta Property Services, Inc.,) from any and all liability, claims, lawsuits, actions, suits, or demands, whether known or unknown, in law or equity, for any and all loss, injury, damage, theft, real or personal property damage, expenses (including attorney’s fees, expert witness fees, paralegal fees, costs and other expenses for investigation and defense and in connection with, among other proceedings, alternative dispute resolution, trial court, and appellate proceedings), and harm of any kind or nature arising out of, or in connection with my, my children’s, and my guests’ use of the facilities and lands owned by the District in connection with the Activity. This shall include, but is not limited to, all claims for damage to property and/or equipment, negligence, partial or permanent disability, the provision of first aid, medical care, medical treatment, or medical decisions, and any claims for medical or hospital expenses.

I know that participating in the Activity may be potentially hazardous, and that I should not participate unless I am medically able to do so. I consent to participate in the Activity and assume all risks associated with such participation including, but not limited to falls, contact with other participants or event personnel, nonparticipants on District property, the effects of weather, facility conditions, and my own physical and mental state of health. I waive any and all claims which I might have based on any of those and other risks typically found in participating in this type of activity. I acknowledge all such risks are known and understood by me. I also acknowledge that it is my own responsibility to ensure that I am sufficiently physically fit to participate in the Activity, but nevertheless agree to abide by all decisions of any official relative to my ability to safely attend/participate in the Activity. I certify as a material condition to my being permitted to participate that I am physically fit and sufficiently able for participation in the Activity and that a licensed Medical Doctor has verified my physical condition.

I expressly acknowledge that I assume all risk for any and all injuries and illness that may result from my, my child’s and my guests’ participation in the Activity, including, but not limited to any injuries sustained by me, my children, and my guests. Without limiting the foregoing, I hereby acknowledge and agree that the District will not in any way sponsor, endorse, supervise or oversee the Activity. This Waiver and Release is binding upon me, my children, my guests, my heirs, executors, legal representatives, and successors. The provisions of this Waiver and Release will continue in full force and effect for each and every time I participate in the Activity and even after the conclusion of my use of the District’s property and participation in the Activity. The provisions of this Waiver and Release may be waived, altered or amended or repealed, in whole or in part, only upon the prior written consent of the District.

I understand that this document is intended to be as broad and inclusive as permitted by the laws of the State of Florida. I further understand that nothing in this waiver and release shall constitute or be construed as a waiver of the District’s limitations on liability contained in Section 768.28, Florida Statutes or other statute or law. I agree that if any portion of this waiver and release is deemed invalid, that the remainder will remain in full force and effect.

I CERTIFY THAT I (OR A PARENT OR ADULT GUARDIAN FOR ALL CHILDREN UNDER 18 YEARS) HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT AND FURTHER UNDERSTAND THAT BY SIGNING THIS DOCUMENT THAT I AM WAIVING CERTAIN LEGAL RIGHTS AND REMEDIES. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. I UNDERSTAND THAT BY SIGNING BELOW, SUCH WAIVER AND RELEASE, INCLUDING ALL OF THE TERMS IN THE PRECEDING PARAGRAPHS, SHALL APPLY TO MY PARTICIPATION IN THE ACTIVITY. *

Signature *

clear

PRIVACY NOTICE: Under Florida’s Public Records Law, Chapter 119, Florida Statutes, the information you submit
on this form may become part of a public record. This means that, if a citizen makes a public records request, we
may be required to disclose the information you submit to us. Under certain circumstances, we may only be
required to disclose part of the information submitted to us. If you believe that your records may qualify for an
exemption under Chapter 119, Florida Statutes, please notify the District Manager.
NOTE TO STAFF: THIS FORM MAY CONTAIN CONFIDENTIAL INFORMATION. DO NOT DISCLOSE ITS CONTENTS
WITHOUT FIRST CONSULTING THE DISTRICT MANAGER.

Heritage Landing Winter Camp Participant Information and Registration

Child's Name

Child 2 (If Applicable)

Child 3 (If Applicable)

Early Bird Special Expires 12/1 Coupon Code: WINTER23

Winter Camp December 26th-29th

Winter Camp January 2nd-5th

Please don't forget to enter the coupon code below to get your. EARLY BIRD DISCOUNT (EXPIRED)

Early Bird Special Expires 12/1 Coupon Code: WINTER23 (EXPIRED)

Adult Primary Contact 1

Adult Primary Contact 2

Emergency Contact

Primary Care Pediatric Contact

Sports and Arts Participation Waiver

Sports and Arts Covid Waiver

HERITAGE LANDING Summer Camp Waiver

Payment