Participant Information and Parent Waiver

If you have not done so already, please fill out this waiver before attending your first Bloom in the Gorge workshop. Girls will not be allowed to stay for our workshop if we do not have a current waiver on file. If you have any questions, please contact us.

We have heard your input and made changes to our curriculum.

Optional massage is no longer a part of our nervous system calming series at the end of workshops. Thank you for your candid feedback in helping us improve to meet your needs!

Child's Name
Parent's Name
List any allergies or medical issues of which the instructor should be aware.
List any information that would be helpful in understanding your child.
How did you hear about Bloom in the Gorge workshops?
Which sessions do you plan on attending?
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Consent
1) I acknowledge that photographs will be taken during the session and agree to them being used in print and online (i.e. websites, Facebook, Instagram). If I do not agree I will advise facilitators. 2) I understand that the facilitators will not discuss what is said in the circle to anyone beyond the circle. The exceptions to confidentiality apply, which are: if the facilitator believes that a participant is at immediate risk of harming herself or someone else, and/or if a minor is a victim of physical or sexual abuse or neglect, or is a witness to a domestic violence or elder abuse. In these instances, the facilitator will need to follow the legal and ethical steps to assure safety to the participants.
Release of Kevin Miller and Bloom in the Gorge from Liability

*Release of Kevin Miller and Bloom in the Gorge from Liability                           

In consideration of the permission granted by Kevin Miller and Bloom in the Gorge (“Kevin Miller/Bloom in the Gorge”) to enroll and participate in the Program, I do hereby release Kevin Miller/Bloom in the Gorge and the employees, assigns, agents, heirs and members of the aforementioned, form all actions, causes of actions, damages, claims, or demands which I, my heirs, executors, administrators, or assigns may have against any and all aforementioned for any and all personal injuries, known or unknown, which I have or may incur by participation in the Program and for all damage to my property.

I realize that there are inherent dangers and risks involved in the Program and I hereby agree to hold Kevin Miller/Bloom in the Gorge and the employees, assigns, agents, heirs and members of the aforementioned harmless from any loss, liability, damage or cost that they may incur due to my enrollment or participation in the Program.

I hereby agree to abide by any policies, rules and regulations adopted by Kevin Miller/Bloom in the Gorge and understand that the violation of said policies, rules and regulations may result in immediate dismissal from the program without refund.

I expressly agree that this release is intended to be as broad and inclusive as is permitted by the law of Oregon and that if any portion thereof is help invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.  I further agree that should any dispute arise in connection with the Program that said dispute will be adjudicated in a court of competent jurisdiction in Hood River County Oregon.

I shall, at my expense, defend, indemnify and hold harmless Bloom in the Gorge LLC against any and all Losses arising out of or in connection with any claim that Bloom in the Gorge use or possession of the Goods infringes or misappropriates the patent, copyright, trade secret or other intellectual property right of any third party.  In no event shall I enter into any settlement without Bloom’s or Indemnitee’s prior written consent.

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