Single Day Trial Registration: TimberNook Tiny Ones

Single Day Trial : Tiny Ones Registration

You are registering for a licensed TimberNook program at Treeline Enrichment, LLC. This form includes essential participant information, waiver and medical release, and payment. Please complete one form per child. Upon submission, the administrator will reach out to you to SCHEDULE your trial on an upcoming Tuesday. If you have any questions before your child’s program begins, please don’t hesitate to reach out.
Program Name
Program Times
Provider Name

Carolyn KrentzAngela RosenburgRyan Rosenburg
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Parent / Guardian Full Name*

First NameLast Name
Parent / Guardian Email Address*
example@example.com
Parent / Guardian Preferred Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (other than the parent / guardian listed above)*
Any MEDICAL conditions or DIAGNOSIS we should be aware of? If none, type NONE*
Does your child take any MEDICATIONS that we should be aware of? If none, please type NONE. *
Does your child have any environmental, medicine, or food ALLERGIES that we should be aware of? If none, please type NONE.*
Optional: Is there anything else about your child that we should be aware of or you would like us to know?
Authorized Adults for Pick-Up: In addition to the parent/guardian listed above, please provide the names of up to three additional adults authorized to pick up your child. These individuals may be asked to show ID. If left blank, only the parent/guardian listed above may pick up the child from this program.
Authorized Adult #1
Authorized Adult #2
Authorized Adult #3
Photo & Video Consent

Treeline Enrichment, LLC may photograph or record your child during participation in its programs. These photographs and recordings may be used, without compensation, for the following purposes: Digital and print marketing (including website, social media, brochures, and flyers); and/or Educational and training use (including staff training, professional presentations, and workshops). Your child will not be identified by name, and no personal identifying information will be shared. This consent is voluntary and may be revoked in writing at any time, except where materials have already been created or used in reliance on this permission.
Do you consent to the use of your child’s photo and video as described above?*

Yes, I give permission.No, I do not give permission.
Sunscreen & Bug Spray Consent

Our programs take place entirely outdoors, and children may be exposed to sun and biting insects. Parents and guardians are encouraged to apply sunscreen and insect repellent to their child prior to arrival and to send any preferred products in the child’s backpack. Treeline Enrichment, LLC staff will not apply or assist in the application of sunscreen or insect repellent during the program without express written consent.
Do you authorize Treeline staff to assist your child with re-application of sunscreen and insect repellent during the program day if needed?*

Yes, I do give permission.No, I do not give permission.
Waiver and Release – Minor
1. I am over the age of 18 and the natural or court-appointed guardian of the minor child(ren) or ward(s) (“Child”) listed above. I choose to allow my Child to participate in {programName} held by TREELINE ENRICHMENT, LLC, on {programDate} (“Activity”). I sign on behalf of and with the intent to bind my Child and his/her assignees, heirs, next of kin, executors, guardians, and representatives as consideration for participating in the Activity.

2. I am aware that the Activity involves inherent risks and dangers, as defined by Section 744.301, Florida Statutes, which cannot be avoided or eliminated and which may impose physiological effects upon my Child including INJURY, DAMAGE, or DEATH.

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR CHILD ENGAGE IN POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF TREELINE ENRICHMENT, LLC, OR ITS OFFICERS, DIRECTORS, MEMBERS, EMPLOYEES, STOCKHOLDERS, VENDORS, AGENTS, REPRESENTATIVES, AFFILIATES, AND CONTRACTORS (“RELEASEES”) USES REASONABLE CARE IN PROVIDING THE ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THE ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM, YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM RELEASEES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM AND RELEASEES HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM. .

3. On behalf of my Child, I hereby WAIVE, DISCHARGE, and agree not to make, assert, or participate in any claim, cause of action, demand, or request for damages, compensation, or other relief, whether known or unknown, against RELEASEES for DEATH, BODILY INJURY, DAMAGE, or any other liability or harm of any sort arising from or involving in any way the inherent risks and dangers associated with the Activity. I intend this waiver to be as broad and inclusive as permitted by law. I HAVE CAREFULLY READ AND UNDERSTAND THIS DOCUMENT. I SIGN IT VOLUNTARILY.

4. This document shall be construed and enforced in accordance with Florida law without reference to its choice of law principles. Any proceeding arising from or involving the Activity or this document shall be subject to the exclusive jurisdiction and venue of the Tenth Judicial Circuit in and for Polk County, Florida.
Parent / Guardian Full Name*

First NameLast Name
Parent / Guardian Signature*

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Date*

MonthDayYear
Date
Medical Waiver & Release
In the event of accident or injury to myself or any of my children (including my child named above) or in the event that my spouse, any child of mine, or I become ill or injured while on the premises of TREELINE ENRICHMENT, LLC, or while participating in any activity sponsored by TREELINE ENRICHMENT, LLC, under any circumstances where I am physically unable to consent or am not present:

1. I CONSENT TO THE FURNISHING TO MYSELF, MY SPOUSE, OR ANY OF MY CHILDREN OF MEDICAL CARE AND TREATMENT BY ANY HOSPITAL OR PHYSICIAN THAT THE HOSPITAL OR PHYSICIAN DEEMS NECESSARY OR ADVISABLE. I AUTHORIZE AND CONSENT TO ANY X-RAY EXAMINATION, ANESTHETIC, MEDICAL OR SURGICAL DIAGNOSIS, OR PROCEDURE RENDERED UNDER THE GENERAL OR SPECIFIC SUPERVISION OF ANY MEMBER OF THE MEDICAL STAFF OR OF A DENTIST LICENSED UNDER THE PROVISIONS OF FLORIDA LAW OR ON THE STAFF OF ANY HOSPITAL HOLDING A CURRENT OPERATING CERTIFICATE. IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS, TREATMENT, OR HOSPITAL CARE BEING REQUIRED, BUT IS GIVEN TO PROVIDE AUTHORITY AND POWER TO RENDER CARE WHICH THE ABOVE-MENTIONED PHYSICIAN IN THE EXERCISE OF HIS OR HER BEST JUDGMENT MAY DEEM ADVISABLE. IT IS UNDERSTOOD THAT EVERY EFFORT WILL BE MADE TO CONTACT THE UNDERSIGNED BEFORE RENDERING TREATMENT TO THE PATIENT, BUT THAT ANY OF THE ABOVE TREATMENT WILL NOT BE WITHHELD IF THE UNDERSIGNED CANNOT BE REACHED.

2. I authorize any officer or member of the TREELINE ENRICHMENT, LLC, or any event volunteer, to consent to such medical care and treatment.

3. I agree to pay the reasonable cost of the medical care and treatment and to indemnify and hold harmless from all liability for such cost the TREELINE ENRICHMENT, LLC, and its officers, directors, members, employees, stockholders, vendors, agents, representatives, affiliates, and contractors.

4. I HAVE CAREFULLY READ AND UNDERSTAND THIS DOCUMENT. I SIGN IT VOLUNTARILY.

5. This document shall be construed and enforced in accordance with Florida law without reference to its choice of law principles. Any proceeding arising from or involving this document shall be subject to the exclusive jurisdiction and venue of the Tenth Judicial Circuit in and for Polk County, Florida.
Parent / Guardian Full Name*

First NameLast Name
Parent / Guardian Signature*

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Date*

MonthDayYear
Date
TimberNook, LLC Terms and Conditions
Please right click to open and review the TimberNook, LLC Terms and Conditions: https://timbernook.com/legal/?v=0b3b97fa6688
Acknowledgment*

By checking this box, I acknowledge that I have read, understand, and agree to the TimberNook, LLC Terms and Conditions. I understand that Treeline Enrichment, LLC is a licensed provider of TimberNook programs, and that participation is subject to the terms, policies, and limitations set forth by TimberNook, LLC.
Payment
Non Refundable Payment is due at the time of registration and secures your child’s spot in the program. By registering, you acknowledge and agree to the following:
- View our Cancellation Policy
- View our Illness Policy

I am registering my child for:

Single Day Trial @ Tiny Ones Product Image

Single Day Trial @ Tiny Ones9:30-11:30 am, ages 18mos -4yrs w/ caregiver. This program is held at Treeline Enrichment, LLC: 701 Sparkman Road, Plant City, FL, 33566

$20.00 Quantity

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Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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Single Day Trial : Tiny Ones Registration

Photo & Video Consent

Sunscreen & Bug Spray Consent

Waiver and Release – Minor

Medical Waiver & Release

Payment