High School Leadership Academy Permission Slip and Waiver of Liabilty
Permission Slip, Release and Waiver of Liability
Name of Student in the High School Leadership Academy *
Your answer
Permission for Participation
By submitting this on-line form submission and the corresponding submit button, which constitutes my electronic signature, I, the parent or legal guardian of the student named at the bottom of this waiver form (referred to as the “Participant”) and who is a participant in the High School Leadership Academy, Ltd. (“HSLA”) during the 2014-2015 school year, including, without limitation, educational workshops and trips, specifically including the trip to the JETS training facility on October 13th in Florham Park, NJ (the “Program”), intending to be legally bound, hereby acknowledge and agree that the Participant is voluntarily participating in the Program and hereby agree to accept any and all risks associated with Participant’s participation in the Program. I understand and acknowledge that Participant may be removed from the Program for, among other reasons, (a) having provided incorrect or false information regarding any portion of his/her application or at any point during the application process; (b) refusal to participate in any portion of the Program; (c) use or possession of illegal drugs; (d) illegal use or possession of alcohol; (e) acts of violence or vandalism; (f) failure to disclose or disclosure of inaccurate, medical information; (g) drunk or disorderly conduct; or (h) failure to comply with any rules or regulations imposed by HSLA or its employees, and agents, including, but not limited to, all terms and conditions of this Agreement. I understand and acknowledge that if Participant is removed from the Program I will be responsible for all expenses HSLA has incurred as a result of Participant having committed any of the acts or omissions for which Participant has been removed from the Program.
Assumption of Risks
By submitting this on-line form submission and the corresponding submit button, which constitutes my electronic signature, I hereby assert that my child's participation is voluntary and I knowingly assume all risks. I acknowledge that my child must strictly adhere to all rules and instructions during the Program. I have consulted a physician of my own choice and have been advised by said physician that Participant is in good health, does not suffer from any physical or mental ailment or disability which requires any medical or surgical care or treatment, or which would make his/her participation in the Program hazardous, unwise, inadvisable or a potential source of danger to Participant or others who may participate in the Program.
Permission for Transportation
By submitting this on-line form submission and the corresponding submit button, which constitutes my electronic signature, I permit my child to be transported to and from the Program in any manner, including transportation by a car or a passenger van driven by an employee or agent of HSLA.
Photo and Video Release
By submitting this on-line form submission and the corresponding submit button, I consent to the use of photographs and video taken by HSLA, or its agents, of my children or me to be used for editorial or promotional uses in any media or electronic form and waive all rights which may arise as a result.
Consent to Medical Treatment
In an emergency, HSLA or its designees will attempt to reach me (my emergency contact) as soon as possible but I understand that should it not be possible to contact me, I authorize any health care provider selected by HSLA or its designee to provide medical care and treatment including, but not limited to x-ray examination, anesthetic, medical, dental or surgical diagnosis, or treatment and medical care which may be recommended and provided under the general supervision of any physician or surgeon, for Participant which, in their judgment, is necessary for the health and well-being of my child. I also permit HSLA or its designees to transport my child to the hospital or medical/dental office if needed.
Release from Liability and Covenant not to Sue
In consideration of HSLA sponsoring the Program and the Participant being permitted to participate in the Program, I, on behalf of myself, my successors in interest, heirs, assigns, and representatives, and the Participant, hereby fully release and hold harmless HSLA and any affiliated entity, their directors, officers, agents, employees, volunteers and representatives, all of whom together shall be referred to as “HSLA Parties”, of and from any liabilities, claims, damages, actions and causes of action whatsoever on account of any loss, damage or injury to person or property or any other loss or inconvenience whatsoever, at any time hereafter arising out of Participant’ voluntary participation in the Program, whether resulting from ordinary negligence of HSLA Parties or otherwise.

Covenant Not To Sue: By submitting this on-line form submission and the corresponding submit button, which constitutes my electronic signature, I acknowledge that I am forever barred from suing HSLA, its officers and its employees, as a result of my child's participation in the Program. I agree to engage in good faith efforts to mediate any dispute that might arise. Any agreement reached will be formalized by a written contractual agreement at that time. Should the issue not be resolved by mediation, I agree that all disputes, controversies, or claims arising out of my participation will be submitted to and be settled by final and binding arbitration in the state of New York in accordance with the then current Commercial Arbitration Rules of the American Arbitration Association. The cost of such action shall be shared equally by the parties. I waive my right to trial by jury.

This Agreement is covered by the laws of the State of New York.

Affirmation of On-Line Submission and Signature. *
Required
Acknowledgement and Certification, Agreement for Electronic Signature
By submitting this on-line form submission and the corresponding submit button, which constitutes my electronic signature, I acknowledge that my agreement to the above is a precondition to Participant’s participation in the Program and that failure to accept this Waiver and Permission Agreement and to agree to its terms would result in HSLA’s denial of Participant’s participation in the Program.

By submitting this on-line form submission and the corresponding submit button, which constitutes my electronic signature, I certify that I am the parent or legal guardian of the Student Name named below (the “Participant”) and, as such, on behalf of myself and the Participant, agree that by signing below, I hereby acknowledge that we have read and understand this two page waiver and permission agreement and agree to be bound by its terms and conditions.

Name of Parent or Legal Guardian *
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Phone number for Parent or Legal Guardian *
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Email address for Parent or Legal Guardian *
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Name of Emergency Contact Person *
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Phone number for Emergency Contact *
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For SPAM protection and verification, please enter the letters HSLA below *
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