Student Information Student Last Name Student First Name Student Age Please check the workshop(s) attending: DIY Desert Terrariums July 10; 10:00am-12:00pm Fun with Summer Blooms July 17, 2024; 10:00am-12:00pm Watercolors in the Main Fountain Garden July 24, 2024; 9:00am-12:00pm Art of Bonsai July 31, 2024; 10:00am-12:00pm Does the student have any allergies? If yes, please specify. Does the student have a allergy that requires the use of an Epi-pen? If yes, please specify. Longwood Gardens must be informed if an epi-pen is carried by the student. Epi-pens cannot be administered by Longwood Gardens Staff. Does the student require mobility or other accommodations? If yes, please specify. Parent/Guardian Information Parent/Guardian Last Name Parent/Guardian First Name Email Primary Phone Emergency Authorization In case of accident or illness, I hereby give permission that my child may be given emergency treatment and, further, I authorize and consent to the administration of any and all medical, dental, and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia, and/or blood transfusions to the below named child that may be ordered by the medical care provider in attendance at the facility deemed necessary for medical treatment. I hereby consent to the release of medical report/s to any medical care provider and consent to the admission of the below named child to a hospital. I hereby consent to be responsible for any medical expenses incurred on behalf of my child. Authorization Checkbox I consent to the above statement. I do not consent to the above statement. Student Name Student Name Authorization Signature Parent/Guardian Signature Authorization Date Photo/Model Release Photo Release Statement For mutually agreed upon consideration, the receipt and sufficiency of which is hereby acknowledged, I, the undersigned, irrevocably authorize Longwood Gardens, Inc. (“Longwood Gardens”), its employees, affiliates, legal representatives, successors, agents, assigns and all those acting on Longwood Garden’s behalf or commissioned to act on Longwood Gardens’ behalf (“Authorized Persons”) to take any form of pictorial, video and/or sound recordings of me (the “Materials”), with right of Longwood Gardens to edit same and to put the finished product to any lawful use that Longwood Gardens may choose in perpetuity and throughout the world. I specifically consent to the use and display of the Materials with other images, text, graphics, film, audio, and audiovisual works. I acknowledge and agree that said Materials may be altered or modified without any restrictions, whether by traditional photographic techniques or digitally. I further grant Longwood Gardens the right and privilege to give, sell, lend, transfer, and exhibit the original Materials or copies thereof to any individual, business, or publication, or to any of their assignees. To the fullest extent permitted by applicable law, I hereby irrevocably waive all legal and equitable rights relating to all liabilities, claims, demands, actions, suits, damages, and expenses, including but not limited to claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory, now known or hereafter known in any jurisdiction throughout the world (collectively, “Claims”) arising directly or indirectly from the Authorized Persons’ exercise of their rights under this Release or the production, exhibition, advertising, promotion, exploitation, or other use of the Materials, and whether resulting in whole or in part from the negligence of Longwood Gardens or any other person, covenant not to make or bring any such Claims against any Authorized Persons and their agents, employees, and representatives, and forever release and discharge the Authorized Persons from liability under such Claims. I agree that this Release cannot be terminated, rescinded, or modified, in whole or in part. THIS RELEASE PROVIDES LONGWOOD GARDENS WITH YOUR ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING LONGWOOD GARDENS TO PUBLICIZE, COMMERCIALLY EXPLOIT, AND OTHERWISE USE YOUR LIKENESS AND NAME AS SET OUT ABOVE. BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS RELEASE AND THAT YOU ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE LONGWOOD GARDENS. The undersigned acknowledges that he/she has read this Release, understands its full meaning, and has executed this Release with full understanding of this Release’s meaning. Authorization Checkbox I consent to the above statement I do not consent to the above statement Student Name Student Name Authorization Signature Parent/Guardian Signature Authorization Date What code is in the image? Enter the characters shown in the image.