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ASTROCURRICULAR

Program Waiver and Consent Form

Emergency Medical Release and Liability Waiver

 

DISCLAIMER

The Arts, Sports, and Technology Resource Organization (herein ASTRO) and its leaders, directors, officers, employees, contractors, agents, volunteers, members, and representatives, are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, competitions, programs, activities or travel with ASTRO and all related activities associated with ASTRO, including any injury, loss, or damage.

PHOTO/IMAGE RELEASE

Occasionally, we will take pictures and/or conduct video recordings during ASTRO programs and events. ASTRO uses the pictures and/or videos on our website and on our social network sites like Instagram, Facebook, and Snapchat, for promotional outreach and fund development capacities. We will never reference you or your child by name or provide specific information regarding you or your child. We also will never sell these pictures and videos; we will use them exclusively for ASTRO social networks and aforementioned purposes. By signing this form, you grant ASTRO permission to use photo and video recordings of you or your child in our promotional materials.

ASSUMPTION OF RISKS

IN CONSIDERATION OF ASTRO allowing me or my child to participate in events, classes, therapy groups, competitions, programs, activities or travel with ASTRO and all related activities associated with ASTRO, including participation in the ASTROCURRICULAR classes, therapy groups, programs, mentorships, volunteer opportunities, seminars, offerings, and all events inclusive, and all activities related to ASTRO, I acknowledge that I am aware of the possible Risk, Dangers, and Hazards associated with participation in activities including the possible risk of severe or fatal injury to myself, my child, or others.

RELEASE OF LIABILITY and AGREEMENT

1. TO ASSUME and ACCEPT ALL RISKS arising out of, associated with or related to my or my child’s participation in the activities.

I Agree

2. TO WAIVE and RELEASE ASTRO from any and all liability for any loss, damage, injury, death, or expense that I or my child may suffer, or that my next of kin may suffer as a result of my child’s participation of the activities due to any cause whatsoever.

I Agree

3. TO INDEMNIFY and HOLD HARMLESS ASTRO from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my or my child’s participation in the activities.

I Agree

4. TO INDEMNIFY and HOLD HARMLESS ASTRO from any and all claims, demands, actions, and costs for any loss, injury, damage or expense whatsoever that may arise out of my or my child’s participation in the activities.

I Agree

PARTICIPATION CONSENT

Acknowledgement of Participant: 

I, the undersigned Participant, understand that I am responsible to act in a safe and responsible fashion, to follow the instructions or directions of the persons in charge of ASTRO activities, and to obey requests and comply with the safety regulations as directed by the persons in charge, including designated leaders and drivers of private or public transportation. I will be solely responsible for myself, will wear a seatbelt when available and will not disturb or distract the driver when using private or public transportation to travel to and from activities. At all sports events and other activities, I acknowledge that it is my responsibility to obtain and wear appropriate safety equipment. I will not endanger the safety of of myself or others at any activities, outings or sports events hosted by ASTRO or when using private or public transportation for travel to and from such activities. I also understand that I may be photographed or appear in video for such purposes as ASTRO deems necessary.

Acknowledgement of Parent/Guardian of Participant

I, the undersigned Parent or Guardian of the Participant, hereby authorize and consent to the Participant’s involvement in ASTROCURRICULAR classes, programs, therapy groups, seminars, offerings, and events inclusive, and all activities related to ASTRO, including any use of private or public transportation deemed necessary by the persons in charge of the event for Participant to travel to and from activities, or to the NEAREST SUITABLE MEDICAL or HOSPITAL FACILITY in the event that emergency or other medical treatment not available at the site of an activity is deemed advisable. I hereby consent to and authorize such emergency or other medical treatment of the Participant as may be deemed advisable in the event of accident, injury, illness, or death during the activities of ASTRO. I also understand that the participant may be photographed or appear in video for such purposes as ASTRO deems necessary.

ACKNOWLEDGEMENT and SIGNATURE

I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors, and/or assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that I, or my child may have.

I Agree

This Consent, Authorization and Acknowledgement shall be effective on September 25, 2020.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Second Participant's Signature*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Third Participant's Signature*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
Tenth 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 sign up for our newsletter.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Health Concerns/Emergency Contacts

List all allergies (to include foods), health problems, medications, or other physical or mental health concerns we should know about: *

Emergency Contact #1 Name *

Emergency Contact #1 Phone Number *

Emergency Contact #2 Name *

Emergency Contact #2 Phone Number *

Insurance Carrier *

Insurance Policy # *
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Gender *
Male
Female
Other
Ethnicity *
Asian
Latino
Caucasian
Pacific Islander
American Indian
African American
Other
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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