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אישור הורים פורסם בתאריך 26/10/2007

לדף המידע מצורף קובץ נלווה

Please Read & Sign

CONSENT, RELEASE AND INDEMNIFICATION

 


The Parent/guardian signing below (“Parent”) hereby consents and gives permission for Parent’s son/daughter _______________________ (“Child”) to participate in Seminar Manhigot  (the  “Event” which term shall include all activities and times during the Event, arrival at and departure from the Event, and early dismissal or expulsion, if any, from the Event) on or about the following date(s) 11/30/07-12/2/07  and any date(s)  to which such Event may be postponed.

In case of medical emergency involving Child, if Parent or another parent or guardian of Child cannot be reached, Parent hereby consents and gives permission to the physician selected by the Event Director to secure necessary and appropriate treatment for Child including hospitalization, anesthesia, surgery and any other emergency treatments deemed necessary by the physician.  Parent agrees that Friends Of Israel Scouts (“FOIS”) is not responsible for any medical expenses incurred by or on behalf of Child, and authorizes FOIS to directly contact and deal with any health insurance company that may provide coverage for Child.

Parent and Child each understand and agree that the Event may include activities involving risk to Child. Parent and Child each represent that Child is in sound physical, mental and emotional health and fully able to participate in all Event activities without need of individualized or specialized attention, accommodation or medical regimen.

Parent and Child each agree that FOIS has the right, in its sole discretion, to determine that Child may not participate in the Event or particular Event activities and, further, in its sole discretion, to determine that Child shall be dismissed or expelled from the Event.

Parent and Child each agree that FOIS may use any photograph, image, likeness, statement or utterance of Child or Parent in any media, including the internet, for promotional or other purposes.

In consideration for Child’s acceptance to participate in the Event, Parent and Child (and Parent on behalf of child), each for themselves, and their heirs, representatives, and next of kin, hereby forever release, waive, discharge and covenant not to sue, and agree to indemnify, defend and hold harmless FOIS and each of their (individually or collectively) affiliates, related entities, officers, directors, employees, volunteers, members, agents and representatives (individually and collectively, “FOIS”) from and with respect to any and all claims, demands, actions, rights of action, and liability, damage, cost, loss and expense (including attorneys’ fees) of any kind whatsoever, past, present and future, both known and unknown, including those which have not yet arisen or matured, either in law or in equity, arising from, related to or in connection with Child’s participation in the Event, including but not limited to claims for negligence on the part of FOIS or any other person or entity, claims under the Americans with Disabilities Act and all other anti-discrimination laws and regulations of any jurisdiction, claims for any delay, property damage, loss or theft, bodily injury, accident, illness, disease, death, mental or emotional injury, and all other claims for damage, cost, loss or expense of any nature whatsoever.

Parent and Child each agree that this and any other agreement related to the Event, and all disputes, issues and matters arising from, related to or in connection with the Event, are to be governed by the laws of the State, without giving effect to principles of conflicts of laws.  Parent and Child each hereby consent to the exercise of personal jurisdiction over each of Parent and Child by the courts of the State and the federal court in connection with any matter arising from, related to or in connection with the Event, or this and any other agreement related thereto, and Parent and Child each further agree that such courts shall have exclusive jurisdiction over all such matters.  If any term or provision hereof is determined to be invalid by a court of competent jurisdiction, the remaining terms and provisions shall remain unimpaired and in full force and effect.


                                               

Parent and Child each have read, understand and agree to the above terms and conditions.

                                                                                                                   

MEDICAL INFORMATION

 

Medical Allergies_________________________________________ Medications ____________________________________

 

Any Medical Conditions__________________________________________________________________________________

 

Health Insurance Company (US) _____________________________________Policy #_______________________________

 

Name of Emergency Contact ___________________________________ Emergency Contact #__________________________

 

Parent/Guardian’s Signature: _________________________ Name: __________________________ Date: ___________________

                                                                            (Please Print)

Child’s Signature:__________________________________ Name: __________________________ Date: ___________________

                                                                            (Please Print)

Full Child’s Name: __________________________________Sex ________Grade _______Email ___________________________

 

Address: ____________________________________City ___________________ State __________Zip _____________________

 

Telephone_(_______)_____________________________ Vegetarian meals required: Yes_____ No _____ Other ______________

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