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EXCURSION/FIELD TRIP WAIVER AND MEDICAL AUTHORIZATION

Date: November 22, 2019

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First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

Field trip:*
I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*

I fully understand that my child is to accept all rules and requirements governing conduct during the field trip.  It is understood that any child determined to be in violation, or unfulfilling of this behavior standard will be sent home at the parents' or guardians' expense.  Parent or guardian has to be ready to pick up the child anytime during the field trip.

I, the undersigned, hereby release and discharge Bionerds, its members and employees (herein collectively referred to as "Company") from all liability arising out of or in connection with the above-described field trip or excursion.  For the purposes of this agreement, liability means all claims, demands, losses, causes of action, suits, or judgments of any and every kind that I, my heirs, executors, administrators or assignees may have against the Company because of any death, personal injury or illness, or because of any loss or damage to property that occurs during the above described field trip or excursion and that results from any cause other than the negligence of the Company.

In the event of any illness or injury, I hereby consent to whatever X-ray, examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child.  It is understood that the resulting expenses will be the responsibility of the parent(s) or guardian(s) or participant.

First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive Bionerds class updates and our newsletter e-mail.
Parent or Guardian's Information

Relationship to child: *

Phone Number: *

Address (Street, City, Zip Code): *
Emergency Contact

Name: *

Relationship to child: *

Phone number: *

Address (Street, City, Zip Code): *
Questions
I have read the Participant Conduct Expectations (LINK): *
Yes
How did you hear about us?*

If Other, please elaborate (type N/A if already chose an option above): *
Health Insurance Information

Health Insurance Company: *

Policy Number: *

Insurance Company Address: *
SPECIAL NOTE TO PARENTS/GUARDIANS:

  • We do not administer drug or medication to your child.
  • We do not provide transportation to and from the field trip site.  The parent or guardian will drop off the child NOT earlier than 10 minutes before the scheduled time, and pick up the child by the scheduled time.  We do not provide day care afterward.

List any allergy if any: 

    • For some field trips, parents are welcome to join us. Some field trip or excursion site has limited number of parent/chaperon allowed or none recommended at all.  Parents and guardians will pay extra fee for their own expenses or admission tickets.


    Initial here: if there are NO special issue(s) or concern(s) that the staff should be aware of regarding your child.

    • If your child has a special medical problem, kindly write below or attach a description of that problem to this sheet.  We will try our best to give special accommodation but no guarantee.

    Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
    Parent or Guardian's Name

    First Name*

    Last Name*
    Parent or Guardian's Date of Birth*
    I certify that I am 18 years of age or older
    Parent or Guardian's Information

    I hereby give my permission for my child and/or myself, to participate in the Bionerds field trip or excursion* as a part of Bionerds Programs specified below:

    Field trip:*
    I give my permission for my child and/or myself to participate in a water activity (choose N/A if not a water activity):*

    I fully understand that my child is to accept all rules and requirements governing conduct during the field trip.  It is understood that any child determined to be in violation, or unfulfilling of this behavior standard will be sent home at the parents' or guardians' expense.  Parent or guardian has to be ready to pick up the child anytime during the field trip.

    I, the undersigned, hereby release and discharge Bionerds, its members and employees (herein collectively referred to as "Company") from all liability arising out of or in connection with the above-described field trip or excursion.  For the purposes of this agreement, liability means all claims, demands, losses, causes of action, suits, or judgments of any and every kind that I, my heirs, executors, administrators or assignees may have against the Company because of any death, personal injury or illness, or because of any loss or damage to property that occurs during the above described field trip or excursion and that results from any cause other than the negligence of the Company.

    In the event of any illness or injury, I hereby consent to whatever X-ray, examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child.  It is understood that the resulting expenses will be the responsibility of the parent(s) or guardian(s) or participant.

    Parent or Guardian's Signature*
    Electronic Signature Consent*
    By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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