WELLSPRING WEEKENDS (Single Session)

WELLSPRING WEEKENDS
Now that we’ve settled into our new home, we are excited to expand our programming with a new 4-week Saturday summer program!

The 4-week session, features four 90-minute classes with each class centered around the baking, production, and marketing of miniature cakes, creating opportunities for creativity, skill-building, and hands on-learning in a fun and supportive environment. Those enrolled will participate in one of the four classes.

Class offerings are listed below:

- Cooking: In this class, we will bake miniture cakes, each week a different flavor.

- Art: The art group will make label designs and thank you cards every week, based on the cakes that are developed in the cooking class.

- Dancin': At the end of four weeks, the dance team will do a flashmob commercial about the cooking class cakes with customized music.

- Production: This group will create videos and reels of the cooking classes cakes for marketing purposes.

Class Dates & Time

The classes are held from 9 AM to 10:30 AM, each Saturday. At the end of the application below, you can choose a single class from one of the following sessions

Session 1 Dates

- June 13

- June 20

- June 27

- July 11

Session 2 Dates

- July 18

- July 25

- August 1

- August 8

Cost

The 4-week program costs $250

Location of Classes

Wellspring Community

200 Wolfensberger Road #100 Castle Rock, CO. 80109

303-660-1935
APPLICATION for PARTICIPANTS
Date of Application:

MonthDayYear
PATICIPANT INFORMATION:
Participant Name:

First NameMiddle InitialLast Name
Date of Birth:

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:
LEGAL GUARDIAN INFORMATION: Is the applicant his/her own guardian?
Name of Legal Guardian

First NameLast Name
Relationship
Legal Guardian Home Phone/Cell
Format: (000) 000-0000.
Legal Guardian Email:
example@example.com
EMERGENCY CONTACT INFORMATION:
Name

First NameLast Name
Relationship
Home Phone/Cell
Format: (000) 000-0000.

MEDIA CONSENT:
I grant Wellspring Community permission to photograph, videotape, record, and use the participant's image, voice, artwork, written statements, and likeness for educational, promotional, fundraising, website, print, social media, and marketing purposes without compensation.
I understand:
- names may be omitted for privacy;
- materials may be used indefinitely unless consent is revoked in writing;
- revocation does not apply retroactively to materials already published.
Media Consent:
Signature of Legal Guardian OR Participant if own guardian:
Date:

MonthDayYear

MEDICAL INFORMATION:
Diagnosis/Disability:
Please describe anything you would like for us to know about this participant in the following areas:
Diet/Eating:
Hearing/Vision/Speech:
Mobility:
Other:
Does this participant have a seizure disorder?
If yes, type:
Date of last seizure
Seizure protocol:
How long do seizures last?
What action do you want Wellspring to take?
If medical attention is required, which hospital do you prefer or does your insurance require?
Is participant independent in toileting?
If no, please explain below the type of assistance needed.
Are there any physical conditions which might restrict program activity?
If yes, please describe:
Are there any behavioral issues we need to be aware of?
If yes, please explain
What interventions are most effective in de-escalating the behavior?
Please describe anything you would like us to know about the diagnosis or anything else you believe will be helpful to know:

MEDICAL EMERGENCY CONSENT:
I authorize Wellspring Community staff, volunteers, and representatives to obtain emergency medical treatment for the participant if I cannot be reached immediately.
I understand reasonable efforts will be made to contact me prior to treatment whenever possible.
I authorize:
- emergency medical treatment,
- hospitalization,
- physician services,
- ambulance transportation,
- diagnostic testing,
- medication administration deemed medically necessary.
I acknowledge:
- the participant is physically and emotionally able to participate except as disclosed in this packet;
- I am financially responsible for medical expenses incurred;
- Wellspring Community does not provide health or accident insurance coverage for participants.
Special medical restrictions or instructions:
Guardian Signature:
Date:

MonthDayYear

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNIFICATION AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING.
I understand participation in Wellspring Community programs and activities may involve inherent risks including, but not limited to:
- falls,
- physical injury,
- illness,
- allergic reactions,
- seizures or medical emergencies,
- transportation accidents,
- behavioral incidents,
- interaction with participants, staff, volunteers, or members of the public,
- exposure to communicable illnesses,
- recreational activity risks,
- and other known or unknown risks associated with community-based and overnight programming.
I voluntarily choose participation for myself and/or the participant and knowingly assume all risks associated with participation, whether known or unknown.
To the fullest extent permitted under Colorado law, I release, waive, discharge, and hold harmless Wellspring Community and its:
- officers,
- directors,
- employees,
- volunteers,
- agents,
- contractors,
- affiliates,
- and representatives
from any and all claims, demands, causes of action, damages, liabilities, costs, or expenses arising from ordinary negligence related to participation in Wellspring Community activities, transportation, programming, or use of facilities.
This release does not apply to conduct that constitutes gross negligence or willful misconduct under applicable law.
I further agree to indemnify and hold harmless Wellspring Community from claims brought by or on behalf of the participant arising from participation in programming.
I understand:
- participation is voluntary;
- I may withdraw participation at any time;
- I have had the opportunity to ask questions before signing;
- this agreement is intended to be as broad and inclusive as permitted under Colorado law.
If any portion of this agreement is deemed unenforceable, the remaining provisions shall remain in full force and effect.
Guardian/Participant Signature:
Printed Name:
Date:

MonthDayYear

PARTICIPANT SAFETY ACKNOWLEDGMENT:
Wellspring Community is committed to maintaining a safe environment for all participants, staff, and volunteers.
Wellspring Community reserves the right to:
- refuse participation,
- request early pickup,
- suspend participation,
- or remove a participant from programming
if behaviors present a significant safety concern to the participant or others.
Guardian Signature:
Date:

MonthDayYear

CLASS SELECTION:
Please choose one class from either Session 1 or Session 2.
Session 1 (June 13 - July 11)
Session 2 (July 18 - August 8)
PAYMENT:

Wellspring Weekend (1 Class / 4 Weeks)

$250.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

WELLSPRING WEEKENDS

APPLICATION for PARTICIPANTS

PATICIPANT INFORMATION:

EMERGENCY CONTACT INFORMATION:

MEDIA CONSENT:

MEDICAL INFORMATION:

MEDICAL EMERGENCY CONSENT:

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNIFICATION AGREEMENT

PLEASE READ CAREFULLY BEFORE SIGNING.

PARTICIPANT SAFETY ACKNOWLEDGMENT:

CLASS SELECTION:

PAYMENT:

*