Student Participants Document

STUDENT PARTICIPANTS DOCUMENT

Student Name:    Student ID:    Date of Birth:

Parent / Guardian (if student is under 18)

Primary Phone:    Email:

Program Participation Details

Start Date:    End Date:

Emergency & Medical Information

Relationship:    Phone:

Relationship:    Phone:

Physician Phone:    Insurance Provider:

Permission to administer non-prescription medications as needed (e.g., acetaminophen, antacid): Yes    No

Legal Acknowledgments, Assumption of Risk, and Release

I, the undersigned (on behalf of the student named above if under age 18), acknowledge that participation in the Program may involve risks, including but not limited to physical injury, illness, aggravation of a pre-existing condition, or other harm. I freely accept and assume all risks associated with participation in the Program, whether foreseen or unforeseen, and accept personal responsibility for any injury, loss, or damage.

In consideration of the student's participation, I release, waive, discharge, and covenant not to sue the organization operating the Program, its trustees, employees, volunteers, agents, and affiliates (collectively, the Organization) from liability for any and all claims, demands, actions or causes of action for injury, death, or damage to person or property arising out of or related to participation in the Program, whether caused by the negligence of the Organization or otherwise, to the fullest extent permitted by law.

I further agree to indemnify and hold harmless the Organization against any claim, loss, liability, expense or damage (including reasonable attorneys' fees) arising out of or related to the student's participation or breach of this agreement, except where such liability is the result of gross negligence or intentional misconduct by the Organization.

Authorization for Emergency Medical Treatment

If the student requires emergency medical treatment while participating in the Program and neither parent nor guardian can be reached, I authorize the Organization and its designees to secure emergency medical treatment and arrange for transportation as reasonably necessary. I understand that I am financially responsible for all costs associated with such treatment.

Authorize emergency medical treatment: Yes    No

Media Release

I grant to the Organization the right to photograph, videotape, or record the student during Program activities and to use such media for educational, promotional, or archival purposes in any media now known or hereafter developed, without payment or other consideration. I understand that identifying information may be used with such media only as necessary for the Organization's educational or promotional purposes.

I grant media release    I decline media release

Behavior, Discipline, and Policy Acknowledgment

I acknowledge that the student must comply with the Organization's rules, codes of conduct, safety instructions, and directions from staff. Failure to comply may result in immediate removal from the Program at the guardian's expense and without refund. The Organization reserves the right to take disciplinary action as necessary for the safety and welfare of participants.

I acknowledge receipt of and agree to abide by the Program's safety and conduct policies: Yes

Certification and Signature

By signing below, I certify that I am the student named herein or the parent/legal guardian of the student, that the information provided on this form is true and complete to the best of my knowledge, and that I have read, understand, and agree to the terms, acknowledgments, and releases set forth in this document.

Sign Now