Medical Information, Release and Media Waiver

Medical Information, Media and Liability Release Forms

Student's Name

First Name

Last Name

Age of Student

Student Date of Birth

YYYY

Parent/Guardian's Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Does your child have any allergies? List any allergies below.

List any other medical conditions for Staff information:

Does your child have any food restrictions? List food restrictions for Staff information:

Does your child require an EPI pen?

Yes

Does your child require medication administered during program hours

If your child is taking medication, we ask that you keep medication in original package, write your child’s name on container and provide a note for medication administration.

Yes

s your child able to participate in all camp activities?

Yes

If no, describe any restrictions

EMERGENCY TREATMENT RELEASE

TO WHOM IT MAY CONCERN: As a parent and/or guardian of the minor named below, I herewith authorize the treatment by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only aYer a reasonable effort has been made to reach me. In case of emergency, The Ohmapi Nature Project has my permission to seek medical treatment for my child.

First Name

Last Name

Doctor's Name

First Name

Last Name

Doctor's Phone

(###)

###

####

PARENT AUTHORIZATION

I certify that the above Health History and Medical Release Form information is complete. My child has permission to engage in all nature program activities except as noted. The Release Form is signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. I agree that all information provided is complete, correct and factual.

Parent/Guardian Name

First Name

Last Name

Date

YYYY

MEDIA RELEASE

The Parent agrees to allow the Student’s name, photograph, voice, image, and information to be used by the Program for use in theProgram's publications, promotion materials, website, and social media sites without compensation and without prior notice. Parent holds the Program harmless from any liability stemming from the use of the Student’s name, photograph, voice, image, or information.

I give permission for The Ohmapi Nature Project to use images of my child in program publications and media.

I do not give The Ohmapi Nature Project permission to use images of my child in program publications and media.

RELEASE OF LIABILITY

In consideration of being allowed to use the facilities and participate in activities (collectively the “Activities”) provided by The Ohmapi Nature Project, Dawn Robinette and Michael Hurst (the “Host”) and The Salvation Army Del Oro, the Participant, and the Participant’s parent(s) or legal guardian(s) if the Participant is a minor, do hereby agree, to the fullest extent permitted by law, as follows: 1) TO WAIVE ALL CLAIMS that they have or may have against the Host arising out of the Participant’s participation in the Activities or the use of any equipment provided by the Host (“Equipment”), including while receiving instruction and/or training; 2) TO ASSUME ALL RISKS of participating in the Activities and using the Equipment, even those caused by the negligent acts or conduct of the Host, its owners, affiliates, operators, employees, agents, and/or officers. The Participant and his/her parent(s) or legal guardian(s) understand that there are inherent risks of participating in the Activities and using the Equipment, which may be both foreseen and unforeseen and include serious physical injury and death; 3) TO RELEASE the Host, its owners, affiliates, operators, employees, agents, and officers from all liability for any loss, damage, injury, death, or expense that the Participant (or his/her next of kin) may suffer, arising out of his/her participation in the Activities and/or use of the Equipment, including while receiving instruction and/or training. The Participant and his/her parent(s) or legal guardian(s) specifically understand that they are releasing any and all claims that arise or may arise from any negligent acts or conduct of the Host, its owners, affiliates, operators, employees, agents, and/or officers, to the fullest extent permitted by law. However, nothing in this Agreement shall be construed as a release for conduct that is found to constitute gross negligence or intentional conduct; and 4) TO INDEMNIFY the Host, its owners, affiliates, operators, employees, agents, and/or officers, from all liability for any loss, damage, injury, death, or expense that the Participant (or his/her next of kin) may suffer, arising out of participation in the Activities and/or use of the Equipment, including while receiving instruction and/or training. Personal Responsibility: The Participant and his/her parent(s) or legal guardian(s) certify that Participant has no physical or mental condition that precludes him/her from participating in the Activities and that he/she is not participating against medical advice. The Participant and his/her parent(s) or legal guardian(s) understand that Participant’s participation in the Activities is voluntary and further understand that they have the opportunity to inspect the Host’s Equipment and facili$es before any participation. The Participant and his/her parent(s) or legal guardian(s) understand that Participant is obligated to follow the rules of the Activities and that he/she can minimize his/her risk of injury by doing so and through the exercise of common sense and by being aware of his/her surroundings. If, while participating in the Activities, the Participant or his/her parent(s) or legal guardian(s) observe any unusual hazard or condition, which they believe jeopardizes Participant’s personal safety or that of others, Participant and/ or his/her parent(s) or legal guardian(s) will remove Participant from par$cipa$on in the Activities and immediately bring said hazard or condi$on to the aXen$on of the Host. To the extent that any portion of this Agreement is deemed to be invalid under the law of the applicable jurisdic$on, the remaining por$ons of the Agreement shall remain binding and available for use by the Host and its counsel in any proceeding. I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I MAY BE WAIVING CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE.

Student's Name

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Date

YYYY