Autrey Mill Nature Preserve and Heritage Center
9770 Autrey Mill Road · Johns Creek, GA 30022
(678) 366-3511 · autreymill@bellsouth.net

2008 Class Registration Form                 

 Class (Name and Date)________________________________________________________________

 Student’s Name ________________________________________

 Age & DOB____________________ (not required for adult students)

 Address _____________________________________________________________________________

 ____________________________________________________________________________________

 Parent’s (or Guardian's) Name ____________________________________________________________

 Home Phone______________________________  Cell Phone _________________________________

 E-Mail ______________________________________________________________________________

 Emergency Contact
    (Name & Phone)  ________________________________________________________________

  Medical Issues
    (Allergies, etc.)     ________________________________________________________________

WAIVER OF LIABILITY

I understand that all athletic and recreational activities involve some risk of accident or injury.  I further understand that Autrey Mill Nature Preserve, herein known as Autrey Mill, of the City of Johns Creek does not provide insurance for participant, nor does it assume responsibility for such accidents or injuries.  Therefore, the choice for my child to participate in any program, activity or facility, and the use of its equipment is at his/her own risk.

I understand, waive, and release Autrey Mill Nature Preserve Association, Inc., lessor and operator of Autrey Mill, and the city of Johns Creek, their employees, contractors and subcontractors, board members, and caretakers from any and all claims, losses, damages, injuries, or other consequences that may arise from their being at Autrey Mill and by such agreement hereby indemnify and hold harmless Autrey Mill Nature Preserve Association, Inc. and the city of Johns Creek at all times the participant is at Autrey Mill.

I authorize Autrey Mill’s personnel associated with Autrey Mill programs to act in my absence and in my behalf to authorize medical treatment to, upon or for the benefit of my child, for any minor injuries which may occur from our participation in any program and associated events.  I recognize that such treatment shall be at my expense.  In the event of a more serious injury that may or may not require emergency treatment, I authorize such personnel to see that my child is transported to and treated at the nearest medical facility at my expense.

I have read, understand, and agree to the policies as stated above.

__________________________________________________                 _________________________
Father/Mother or Guardian Signature                                                                             Date

Autrey Mill Nature Preserve and Heritage Center
9770 Autrey Mill Road · Johns Creek, GA 30022
(678) 366-3511 · autreymill@bellsouth.net

2008 Class Registration                 

Publicity Release

Participants in Autrey Mill classes will be involved in activities that may be publicized through local or national news media.

___  I grant permission for my child to participate in any publicity activities for events sponsored by Autrey Mill Nature Preserve and Heritage Center.  Such activities may include interview sessions with news reporters; photographs for newspapers or various Autrey Mill publications including newsletters, calendars, and brochures; videotaping for local and national television newscasts, cable programming, and promotional videos; and photographs for the Internet pages of the Autrey Mill website.  I understand that this permission is effective as long as my child attends classes at Autrey Mill Nature Preserve and Heritage Center.

 ___  My child may not participate in any publicity activities for events sponsored by Autrey Mill Nature Preserve and Heritage Center.

__________________________________      _____________________________________________
Student’s Name                                                        Parent or Guardian’ signature

 _____________________
Date