ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

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* 1. Please enter your contact information

Name *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

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* 2. Please check all that apply

I have been symptom free for the past two weeks

No one in my family/household is showing flu-like symptoms

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* 3. Please certify that you will observe and follow all these rules when visiting the farm by checking each box

Negotiate for safety! Assume that it is not okay to give others hugs or handshakes. Actively negotiate and ask for consent before handshakes, hugs, or being in close proximity to others.

Keep it at 6! Unless negotiated differently, maintain 6 feet of distance from all other persons. We know that being out at the farm can involve being closer than 6 ft. Be proactive in these situations, and ask yourself and others what feels comfortable (e.g. masking, working most closely with members of your pod)

Keep It On You! Always have a mask in your possession. Be prepared to mask-up during some group activities (when asked by an MGF staff member) and while in enclosed spaces including the greenhouses or garage (always!)

Prioritize the most cautious! Work to accommodate the highest risk (or most cautious) community member present! Notice someone else taking more precautions than you? Ask what would make them feel most comfortable.

Get tested and stay home if you are sick or exposed! When in doubt about a possible exposure and/or & feeling ill, stay home and get a COVID test.

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* 4. 2. RELEASE OF LIABILITY FORM
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED with my visit to 592 Puncatest Neck Road, Tiverton RI, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.
I certify that I am sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity.

I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.
In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: Movement Ground Farm, Puncatest Heights Land Collaborative, Michio Ishihara, Melody Ishihara, and Kohei Ishihara, and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;

(B)INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.
I acknowledge that they are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

I acknowledge that this activity may involve risks that include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants but are also present for volunteers.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

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* 5. DO YOU CERTIFY THAT YOU HAVE READ THIS DOCUMENT AND YOU FULLY UNDERSTAND ITS CONTENT?

Yes

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* 6. ARE YOU AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT YOU ARE SIGNING IT OF YOUR OWN FREE WILL?

Yes

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* 7. IF YOU AGREE WITH THE FULL CONTENT OF THE AGREEMENT, AND WISH TO SIGN THIS FORM, CHECK THE BOX

By checking this box, I am providing my full consent, and this constitutes my signature.

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* 8. WHAT IS TODAY'S DATE?

Date / Time

Date

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* 9. IF YOU ARE UNDER THE AGE OF 18, YOUR PARENT OR GUARDIAN MUST PROVIDE THE FOLLOWING INFORMATION (ANSWER ONLY IF APPLICABLE)

FIRST AND LAST NAME OF PARENT OR LEGAL GUARDIAN

PHONE NUMBER

E-MAIL ADDRESS

TODAY'S DATE

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* 10. AS A PARENT OR LEGAL GUARDIAN OF THE PARTICIPANT, DO YOU CONSENT TO THE AGREEMENT?

Yes