Please take a few minutes to complete this form and digitally sign the release. Every participant must submit this form prior to participating in an Au Sable Institute program.
Program Description and Dates: Jackson Free Methodist Church Winter Weekend at Au Sable Institute January 25, 26, 27, 2019 If you have any questions you can email Liann at email@example.com
Assumption of Risk and Agreements of Release and Hold HarmlessI acknowledge that I have read and understand the description of this program and have noted any medical or physicalconditions that might affect the participant’s performance in this activity. I understand that this program involves knownand inherent risks, as well as unknown/unanticipated risks. Inherent risks may include those ordinarily associated withphysical activity in outdoor environments.
In consideration for Au Sable Institute permitting me or my child to participate in this program, I hereby, for myself, myheirs and survivors, release Au Sable from all personal injury, property damage, loss of personal property, or any otherloss sustained by me or my child while participating in this program, including travel to and from the program site, andagree to hold harmless Au Sable and its employees, representatives and volunteers from any and all claims made by me,my child or my heirs and survivors. In case of accident or illness I will bear the cost of all emergency procedures andmedical care.
Release Authorization for Medical Treatment for MinorsIf the participant is under the legal age of consent (18 years), the law requires that we have a parent’s permission to givemedical service should the need arise.
The undersigned, who is one of the parents having legal custody, or the legal guardian, of the minor participant namedabove, hereby gives permission to personnel of Au Sable Institute to authorize any X-rays, tests, procedures, anesthetic,surgery or treatment on behalf of, and to provide or arrange for any transportation of, participant as may be required inthe event of an emergency. I authorize Au Sable personnel, if necessary, to administer epinephrine via Epi-Pen injectionfor emergency treatment for anaphylactic shock. If the emergency contacts designated on this form cannot be timelycontacted, I hereby give permission to a licensed physician, or other qualified health care provider as may be appropriate,to administer such treatment to participant as may be necessary under circumstances, including hospitalization of thepatient. I also agree to assume any financial responsibility for my child’s care.
Photo ReleaseI authorize and consent to Au Sable Institute taking photographs and video film of the participant in itsprograms, and to the unrestricted use and publication of such photos or videos to promote the activities of AuSable Institute. (No names will be used without obtaining prior written consent.)