Adventures with Jacob's Chance - Spring '24 Fishing Club

Adventures with Jacob's Chance presents:

Fishing Club with Beyond Boundaries!

Registration for each date closes when at capacity

Join Jacob's Chance, Beyond Boundaries, and our awesome volunteers for an afternoon of fishing. We'll learn about the different types of fish we'll catch, and see if we can identify each one!

Dates: Mondays, May 6th - June 10th (exception: We'll be fishing on Tues, May 28th instead of Memorial Day!)

Time: 4:30-6pm

Locations: TBA! Some places we plan on going include Bryan Park, Shield's Lake at Maymont, Dorey Park, and Deep Run Park. We'll let you know where we're fishing several days in advance. (We check water/weather conditions at the ponds each week!)

Cost: $10/day

Ages: 5-40

Which dates are you registering for?

Please check all that apply

May 13th

May 28th

June 3rd

June 10th

Amount *	Quantity
$10 - Fishing fee per day (select quantity)
$5 - Partial financial assistance per day (select quantity)
$0 - Total financial assistance

Optional Donation - Support the Mission!

$100

$50

$25

$10

Family Contact Information

Parent/Guardian Name

First Name

Last Name

Verify Email

Phone

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Participant 1 Information

Name

First Name

Last Name

Birthdate

(mm/dd/yyyy)

Participant Diagnosis

Any accommodations requested/helpful tidbits?

Is there anything we should know about the participant to ensure they have the most success possible?

Demographic Data

Data collection is used only for grant compliance and internal review purposes. Check all that apply

Caucasian

Black or African American

Asian

Indigenous American or Native American

Native Hawaiian or Pacific Islander

Hispanic or Latino

Not of Hispanic Origin

Not interested in reporting

Gender Identity

Male

Female

Non-binary

Other

Requested pronouns (examples: he/him, they/them, she/her)

Media Wavier

Jacob’s Chance has my permission to use my and/or my child’s photograph publically to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I agree to the terms established by the above media waiver.

Yes

Health and Safety Waiver

In consideration of being allowed to participate in any way in the program, related events and activities, and use of equipment, I the undersigned, acknowledge, appreciate, and agree that:

The risk of injury from the activities involved in this program is significant, including the potential for paralysis and death.
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others and assume full responsibility for my participation.
I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Host, it’s officers, officials, agents, and/or employees, other participants, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to a person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
COVID-19 ACKNOWLEDGMENT AND WAIVER: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. While Jacob’s Chance is taking reasonable steps and precautions to lessen the risk of transmission of COVID-19 or other communicable diseases, and while Jacob’s Chance is following CDC guidelines and applicable state and county health department guidelines and orders, it is not possible to prevent against the presence of these diseases. THEREFORE, I RECOGNIZE AND UNDERSTAND THAT Jacob’s Chance is not responsible in any manner for any risks related to communicable diseases in connection with Participant’s participation in the activities. Specifically, I understand that COVID-19 is a highly contagious and dangerous disease and that contact with the virus that causes COVID-19 may result in loss, damage, expense or significant personal injury, sickness or death. I am fully aware that participation in the Activities carries with it certain inherent risks related to the transmission of communicable diseases that cannot be eliminated regardless of the care taken to avoid such risks, including, but not limited to: (1) the risk of coming into close contact with individuals or objects that may be carrying a communicable disease; (2) the risk of transmitting or contracting a communicable disease, directly or indirectly, to or from other individuals; and (3) injuries and complications ranging in severity from minor to catastrophic, including death, resulting directly or indirectly from communicable diseases or the treatment thereof (“Inherent Risks”). Further, I understand that all of the Inherent Risks are not fully understood and that the exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine. I hereby voluntarily accept and assume all risk of loss, personal injury, sickness, death, damage, and expense for myself arising from such Inherent Risks.

Furthermore, I represent and warrant that I do not knowingly carry any communicable diseases that may be transmitted during participation in the activities.

Health Statement

I will notify Jacob’s Chance ownership or employees if I suffer from any medical or a health condition that may cause injury to myself, others, or may require emergency care during my participation.

1365 Overbrook Rd, Richmond, VA 23220

804-640-8109

info@jacobschance.org

I agree, on behalf of the participant/s, to the terms established by the above health and safety waiver.

Yes

Individual responding to above waivers:

First Name

Last Name

Add 3% to my total amount to help cover the payment processing fees