Fill and Sign the Registration and Medical Release Form for Minors to Participate in Roofing Earn While You Learn Program

Registration and Medical Release Form for Minors to Participate in Roofing Earn-While-You-Learn Program I. Registration Information Last Name ________________________________________________ First Name _____________________________ MI _____________ Nickname _________________________________________________ Address _______________________________________________ City ___________________________ State __________ Zip ____________ Phone Number __________________________________________________ Birthday (Month, year and day) _________________________________________ Email address _________________________________________________ II. Emergency Medical Information ( Medical information on this form will only be used if medical treatment is needed. It will be used for no other purpose). Social Security Number _______________________________________ Date of last Tetanus shot _______________________________ Medication(s) you are currently taking (prescribed & over-the-counter):  ___________________________________________________________  ___________________________________________________________  ___________________________________________________________  ___________________________________________________________  ___________________________________________________________ Medication(s) you CANNOT take:  ___________________________________________________________  ___________________________________________________________  ___________________________________________________________  ___________________________________________________________  ___________________________________________________________ Any allergies &/or special health problems or concerns:  ___________________________________________________________  ___________________________________________________________ Medical Insurance Information: Company Name _____________________________________________________  Phone _______________________________________________  Address _______________________________________________  City ___________________________ State __________ Zip ____________  Policy #_______________________________________________  Policy Holder’s ID #_______________________________________________  Relationship to policyholder_______________________________________  Is this Plan an [ ] HMO or [ ] PPO  Is pre-authorization required to obtain treatment? [ ] Yes [ ] No  Is a second opinion required before surgery? [ ] Yes [ ] No In an emergency, please contact:  Name _______________________________________________  Relationship _______________________________________________  Address _______________________________________________  City ___________________________ State __________ Zip ____________  Day Phone ___________________________  Evening Phone ___________________________  Cell Phone ___________________________ Physician information:  Physician’s Name _______________________________________  Address _______________________________________________  City ___________________________ State __________ Zip ____________  Phone Number ____________________________________ Medical Release In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation in _______________________ (Name of Program) , every reasonable effort will be made to contact the persons listed above. If unsuccessful in contacting the persons listed, consent and permission is hereby given for treatment by competent medical personnel. Further, unless specified otherwise, consent and permission is hereby given to all adult employees of _______________________ (Name of Program) to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery (under recommendation of qualified medical personnel). I understand that the ______________________ (Name of Program) does not carry accident or medical insurance on its participants in this Program. I agree that my insurance company will be used for such medical care expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any medical bills. _____________________________________ (Printed Name of Student Participant) _____________________________________ Date: _____________________ (Signature of Student) _____________________________________ (Printed Name of Parent or Guardian) _____________________________________ Date: _____________________ (Signature of Parent or Guardian) _____________________________________ (Printed Name of Policyholder) _____________________________________ Date: _____________________ (Signature of Policyholder) III. Release and Waiver of Liability This Release and Waiver of Liability (the Release ) is executed this the ___________________ (date) by the undersigned Participant and the Parents or Guardian of Participant in favor of _____________________________ ( Name of Organization) which has its principal office at _________________________________ ______________________________________ (street address, city, state, zip code) , and is hereinafter referred to herein as Organization. Said Participant and his or her Parents or Guardian are hereinafter sometimes jointly and severally referred to as the Releasors. Whereas, Participant desires to participate in the R oofing Project Earn-While- You-Learn program (the Program ) sponsored by Organization; and Whereas, this program involves working on private homes under tutelage of a master carpenter; and Whereas, understands that the activities will include construction work more particularly described in Exhibit A attached hereto and made a part hereof by reference; and Whereas, one of the conditions of participating in the Program us the execution of this Waiver and Release; Now, therefore, for and in consideration of being allowed to participate in the Program, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Release and Waiver. Releasors hereby release and forever discharge and hold harmless Organization, its officers, directors, employees, volunteers and/or agents (hereinafter referred to jointly and severally as the Releasees ) from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from Participant’s activities with the Program. Releasors understands that this Release discharges Releasees from any liability or claim that the Releasors may have against Releasees with respect to any bodily injury, personal injury, illness, death, financial or property damage that may result from Participant’s activities in the Program, whether caused by the negligence of Releasees or otherwise. Releasors also understand that Releasees do not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness of participants in the program. 2. Assumption of the Risk. Releasors understand that the activities of the Program include those described in Exhibit A and may be hazardous to the Participant. Releasors hereby expressly and specifically assume the risk of injury or harm in the said activities and release Releasees from all liability for injury, illness, death, financial or property damage resulting from such activities. 3. Personal Property. Releasors understand that any or all personal property damaged or lost is not the responsibility of Releasees. 4. Indemnification Releasors also agree to indemnify and hold harmless Releasees with respect to any and all actions, claims or demands (including attorney’s fees) that may accrue or be made or brought by the undersigned, someone on the behalf of the undersigned, the Participant, or someone on behalf of the Participant, against Releasees which arise out of or is in connection with Participant’s participation in the Program, whether such claim, demand or action is the result of the negligence of Releasees or otherwise (except if directly caused by the gross negligence or wanton and willful misconduct of Releasees). 5. Releasors expressly agree that this Waiver and Release is intended to be as broad and inclusive as permitted by the laws of the State of _________________ (name of state) , and that this Waiver and Release shall be governed by and interpreted in accordance with the laws of the State of ________________ (name of state) . Releasors further agree that in the event that any clause or provision of this Waiver and Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Waiver and Release which shall continue to be enforceable. WITNESS our signatures as of the day and date first above stated. ________________________ _________________________ (P rinted Name of Participant) (P rinted Name of Parent) ________________________ _________________________ (Signature of Participant ) (Signature of Parent) _________________________ __________________________ (P rinted Name of Parent) (P rinted Name of Guardian) _________________________ __________________________ (Signature of Parent ) (Signature of Guardian)