Event Waiver – Expanding Boundaries International

A. Waiver

Event/Program Name (please select the event you will be participating in):

STEAM Exchange SATURDAYS

Day Trip to Korean Embassy in Washington, DC

Day Trip to Philadelphia (Puerto Rican Cultural Center)

STEAM Exchange CyberCamp

Participant Name

First Name

Last Name

Minor (For participants under 18 years of age, the parent or guardian completes this section in addition to Sections A and B; and C, where applicable.)

Minor Participant's Name:

First

Last

Gender

Female

Male

Age:

Date of Birth

I, the Guardian of the above named Participant, do hereby give my consent to his/her participation in all activities related to the event listed in Section A.

Parent/Guardian (on behalf of Minor Participant)

First

Last

Participant/Guardian Signature

Clear

Email

Confirm Email

Phone

Waiver and Release: We, the Participant and/or the Guardian, Release and forever discharge and hold harmless Expanding Boundaries International and its successors and assigns 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 the activities as a participant with Expanding Boundaries International, including claims arising out of negligence. We understand and acknowledge that this Release Discharges Expanding Boundaries International from any liability or claim that we may have against Expanding Boundaries International with respect to bodily injury, personal injury, illness, death, or property damage that may result from the Participant’s involvement in the Expanding Boundaries International activities.

I understand

Photographic Release: I, the undersigned, do hereby grant permission to Expanding Boundaries International Inc. (EBI) and its sponsors and partners to post me and/or my child’s story, photo, or another item, hereinafter referred to as “Materials,” I submit to and for Expanding Boundaries International’s and its partners and sponsors' Website, and social media sites. I hereby release you, your representative, employees, managers, members, officers, parent companies, subsidiaries, and directors, parters and sponsors, from all claims and demands arising out of or in connection with any use of said “Materials”, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights. I acknowledge and agree that no sums whatsoever will be due to me as a result of the use and/or exploitation of the “Materials” or any rights therein.

I Approve

I don't Approve

Medical Treatment: We, the Participant and the Guardian, hereby Release and forever discharge Expanding Boundaries International and their team from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during the Participant’s activity with the Nonprofit. We give our consent for the Nonprofit to provide, administer, or obtain medical treatment for the Participant.

I understand

Other: We, the Participant and/or the Guardian, expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Maryland and District of Columbia and that this Release shall be governed by and interpreted in accordance with the laws of the State of Maryland and District of Columbia. We agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

I understand

By signing below, I express my understanding and intent to enter into this Release and Waiver of Liability knowingly and voluntarily.

Particpant/Guardian Signature

Clear

Date

B. Medical Authorization

The Participant and the Guardian are responsible for the Participant’s own insurance coverage in the event of personal injury or illness as a result of participation in activities with Expanding Boundaries International. In the event of any illness or injury while participating in the event listed in Section A, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care from a licensed physician, surgeon, and/or dentist as deemed necessary for my safety and welfare. It is understood that the resulting expenses will be my responsibility.

I understand

Participant’s Medical Insurance Carrier:

Check here if the participant has a special medical condition and attach a description or describe that condition to this form or provide a brief description in the field below:

Medical Description (Brief Description Details)

Medical Condition Description Details

Maximum file size: 516MB

Medications

Check here if there are NO medical conditions that the staff should be aware of and if your son/daughter is NOT required to use any medications during this event.

Check here if your son/daughter must take medication(s) during the excursion/field trip and list them on this form or hereto attached. All medications, except those which must be kept on the minor’s person for emergency use, must be kept and distributed by Expanding Boundaries International staff.

Name of medication(s) and reason for use:

Emergency Contact: In the event of illness, accident, or other emergencies, please notify:

Name

First

Last

Phone

Relationship to Participant

Other person(s) you would like us to contact (optional):

Phone Number(s):

C. Transportation

I do hereby fully release and forever discharge Expanding Boundaries International, and their officers, agents, servants, and employees (collectively, the “Releasees”) from any and all claims for injuries, damages or loss that I may have or which may accrue to me and arising out of, connected with, or in any way associated with said transportation services. By checking this box below on this document acknowledges that I have carefully read these provisions and I fully understand and willingly agree to abide by these terms.

I understand

N/A. I will be providing my own transportation to and from the event.

I have read, understand and agree to all provisions of Section A: Waiver; Section B: Medical Authorization; and Section C, as appropriate; as related to my participation and/or my son/daughter’s participation in this event.

I understand

Participant/Guardian Signature

Clear

Date

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