Name

Address

Address

City

State

Zip

Email

Home Phone

Cell Phone

Date of Birth

Gender

Male Female

Grade Level as of 05/08

Desired Session

Please check one:

Session 1 June 14th through June 20th ___

Session 2 June 21st through June 27th ___

Session 3 (2 WEEKS) June 28th

though July 4th ___

Session 4 ALUMNI WEEK July 12th through July 18th ___

Session 5 July 19th through July 25th ___

Session 6 August 2nd through August 8th___

Session 7 August 9th through August 15th ___

Session 8 August 16th through August 22nd ___

Please Describe Any and All Food or Other Allergies, Religious Restrictions Concerning Diet for Your Camper. Please Be Very Specific.

Allergies and Religious Restrictions

Please Specifically Describe Any and All Behavioral and/or Medical Conditions or Handicaps of Your Camper

Behavioral and/or Medical Conditions or Handicaps

Please List Each and Every Medication(s) Required to Be Administered to Your Child, Conditions of Administration, Time and Schedules

Medications Required, Conditions of Administration, Time and Scheduling

Please Provide Complete Information of All Current Physicians for Your Camper. Include Name, Address, Telephone Number(s) and Emails

Current Physician'(s)' Information

Camper's T- Shirt Sizes (Adult Sizes Only - Check One

xs s m l xl

Will this be your camper's first overnight camp? yes no

Will your camper be attending our camp with any relatives or friends? If so, with whom? Relatives of Friends Attending with Camper

B. Contact Parents' Information:

Name

Address

Address

City

State

Zip

Email

Home Phone

Cell Phone

Work Phone

C. Other Parent of Emergency Contact

Name

Address

Address

Relationship to Camper

City

State

Zip

Email

Home Phone

Cell Phone

Please Carefully Read the Following Parent/Guardian Authorization and General Release in its Entirety :

AUTHORIZATION, PERSONAL AND GENERAL RELEASE FROM LIABILITY:

I hereby certify that I am a parent or guardian with legal c ustody of the above named Camper and that he/she has my permission to engage in all of The Kids’ Culinary Academy of Vermont instruction, trips and activities, including but not limited to, use of kitchen utensils and knives; food handling; kitchen cleaning, food preparation, cooking and baking; boating; swimming; aquaponics; beekeeping; general gardening; touring of and travel to and from factories, exhibitions and farms; camping; hay rides; and campfire and outdoor cooking activities. I hereby give permission to staff, employees and agents of The Kids’ Culinary Academy of Vermont to provide routine health care, administer prescribed medications, and seek emergency medical treatment, including, but not limited to ordering x-rays or routine tests. I agree to the release of any records necessary for insurance or other medical purposes. I give permission to The Kids’ Culinary Academy of Vermont to arrange necessary related transportation to my Camper with respect to any and all of the foregoing. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by The Kids’ Culinary Academy of Vermont to secure and administer treatment(s), including hospitalization, for the Camper named above. This completed form may be photocopied for trips off theCamp premises or for other reasonably necessary purposes.

I, the undersigned, hereby grant permission to The Kids’ Culinary Academy, its/their agents, successors, assigns, field producers and/or representatives to photograph/record//video my Camper and to record his/her voice, performances, poses, acts, plays and appearances, and use his/her picture, photograph, silhouette and other reproductions of his/her physical likeness and sound for The Kids’ Culinary Academy purposes and the unlimited distribution, advertising, promotion, assignment, exhibition and exploitation of the Pictures by any method or device now known or hereafter devised in which the same may be used, and/or incorporated and/or exhibited and/or exploited. I agree that I will not assert or maintain against you, your successors, employees, investors, managers, agents, assigns and licensees, any claim, action suit or demand of any kind of nature whatsoever, including but not limited to, those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any other reason in connection with your use of my physical likeness and sound as herein provided in any production(s) whatsoever. I hereby release you, your successors, agents, employees, investors, managers, assigns and licensees from causes of action(s), costs and expenses whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I ever had, now have, or may, shall or hereafter have by reason, matter, cause or thing arising out of your use as herein provided.  I affirm that neither I, nor anyone acting for me, gave or agreed to give anything of value to any of your employees, agents or any representative of any televised station, network or production entity for arranging my Camper's appearance on the Pictures. I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, I have signed this release. I represent that I am the parent/guardian of the minor Camper named above and further I agree that the grant and release contained herein binds me and said minorCamper to all of the terms thereof.

I have enrolled the above named Camper in one or more of the weekly sessions (collectively the "Session(s)") of The Kids’ Culinary Academy. I understand the above named Camper's participation in The Kids’ Culinary Academy Session(s) involves exposure to inherent risks that cannot be eliminated. I also understand that my Camper's participation in the Session(s) may require the use of knives, forks and spoons and kitchen equipment, food and food handling equipment, and boats and boating equipment, gardening equipment, outdoor cooking equipment and other similar tools and instructional and recreational gear which have the potential risk of injury. Individually, and as the parent or guardian of the Camper, I HEREBY EXPRESSLY ASSUME ALL RISKS associated with the Camper's participation in the Session(s) including all risks associated with the above and any and all other of The Kids’ Culinary Academy of Vermont activities. Despite my understanding of the foregoing risks, I, individually and as the parent or legal guardian of the Camper, AGREE NOT TO SUE AND TO RELEASE FROM LIABILITY AND TO DEFEND, INDEMNIFY AND HOLD HARMLESS THE KIDS’ CULINARY ACADEMY OF VERMONT, and their representatives, owners, employees and agents for any damage or injury arising out of the Camper's participation in the Session(s) regardless of the cause, including NEGLIGENCE.

I understand that the foregoing is a LIABILITY RELEASE and a
MEDICAL AUTHORIZATION that is legally binding on me, the Camper, our heirs, assigns and our legal representatives, and further that II sign/submit it of my own free will. I acknowledge on behalf of myself and the Camper that the foregoing is binding and of legal effect during the entire 2008 summer camp season and in perpetuity. By clicking the button below, I certify that I am the individual described in paragraph B above and agree to all of the foregoing in perpetuity.

I am making required initial payment:

via electronic payment check

Thank you. Once you have submitted this Completed Application (STEP 1) and Paid the Initial Payment STEP 2, Your Camper is enrolled in the Session You Have Chosen. We will contact you via email if there are any questions or problems or you may call 802-868-3030 to confirm your Camper's Enrollment. If you paid a 50% deposit, your final payment will be electronically invoiced to you for payment on or before May 1, 2009.