Waiver and Consent for Attendance and Medical Treatment
In consideration of participation in the event, “Key to College” at the San Francisco State University Campus hosted by Circle K at San Francisco State University on Saturday, February 10, 2018 from 9:30 AM to 3:30 PM, I, __________________(participant) give my consent as follows: Understand and agree that my image may be captured in photographs or video and used in publications, including, but not limited to, posting of my image on the internet. I give permission to do so and my waiver and release in this document applies to those uses as well. I additionally release Kiwanis, Kiwanis Service Leadership Program groups, its agents, representatives, directors, officers, and members from all liability from any and all injuries that may occur by the use of my picture, image, name, or other materials stated herein. I understand and agree that all rights under Section 1542 of the California Civil Code are hereby waived. That in the event of a medical emergency, I understand that every effort will be made to contact the emergency contact listed below. In the event they cannot be reached or time does not permit, I hereby give permission to any responsible adult who is acting as a chaperone to authorize any medical treatment deemed necessary and proper by any licensed physician or other medical provider. Furthermore, I understand and agree that if such medical treatment is not covered by my personal medical insurance, I will be solely and completely responsible for any and all financial costs associated with that medical treatment.
Known allergies or medical conditions: ____________________________________________________ Currently taking the following medications: _________________________________________________
Medical Insurance Policy Carrier: ____________________ Policy Number: ___________
Emergency Contact: ________________________ Relation: _______________________
Phone #1: __________________________
I have read and agree to all terms and conditions stated herein and I hereby RELEASE, WAIVE, AND FOREVER DISCHARGE Kiwanis International, Circle K International, the California-Nevada-Hawaii Districts of Kiwanis and Circle K, as well as all of their agents, employees, trustees, volunteers, affiliated clubs, officers, directors and members, from any and all liability for any claim, damage or injury, including but not limited to physical and/or emotional injury, medical and/or psychological expenses, and attorney’s fees, arising from or related to participation in this event.
Name: __________________________Signature: ________________________ Date: ______________
IF THE PARTICIPANT IS UNDER 18 YEARS OF AGE, THE FOLLOWING MUST ADDITIONALLY BE SIGNED BY A PARENT OR GUARDIAN
I, ___________________________, am the parent/legal guardian of the above named. I have read and agree to all terms and conditions and give my consent and agree to the foregoing on behalf of the participant.
Name: __________________________Signature: ________________________ Date: ______________ Relation: ________________________