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Participant Agreement, Liability Waiver, and Assumption of Risk

Instructions:

All participants in any Experiential Learning program or other outdoor program facilitated by Sierra STEM must complete this Participant Agreement, Liability Waiver, and Assumption of Risk (“Liability Waiver”) prior to participation. Participants in this program must also complete and submit the following Supplementary Forms which are attached at the end of this document:

  • Participant Health Form (Basic)
  • Participant Image and Likeness Release

To indicate acceptance of this agreement, a Parent or Legal Guardian (“Parent/Guardian”) of the Participant must indicate acceptance of this agreement by signing at the end of the form.


In consideration of my participation in programs facilitated by Sierra STEM and the services provided by Sierra STEM, its agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “Sierra STEM”), I hereby agree to release, indemnify, and discharge Sierra STEM, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representatives, and estate as follows:

1. Assumption of Risk: Acknowledgements, Representations, and Warranties

I understand and willingly agree that my participation in this program facilitated by Sierra STEM is undertaken with full understanding and appreciation for the risks and that I undertake participation solely at my own request and risk. My participation in this activity is purely voluntary; no one is forcing me to participate and I elect to participate in spite of and with full knowledge of the inherent risks, as described below.

I have carefully read and agree with the following statements:

I understand that there are risks associated with outdoor activities and hiking, which include, but are not limited to:

  • Injuries and illnesses related to hot or cold weather including severe sunburn, dehydration, heat exhaustion, heat stroke, hypothermia, and frostbite;
  • Injuries and illnesses related to natural disasters or “acts of nature” including earthquake, geothermal exposure, avalanche, rockfall or landslide, falling objects or trees, wind, lightning strike, flash flood, inclement weather, animal attack/encounter, insect bites/stings, and hazardous plants;
  • Injuries, including drowning, related to water features such as lakes and river or creek crossings;
  • Injuries related to snow or ice including obstacles hidden by or below the surface of snow and ice;
  • Injuries related to rocks, climbing, or falling including broken bones, severe injuries to the head, neck, and back which could result in severe impairment or death;
  • Injuries related to hiking, including blisters, and specifically hiking on uneven trail and terrain surfaces, including slips, falls, pinches, scrapes, twists, and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or more severe life-threatening hazards;
  • Injuries related to physical exercise and exertion;
  • Injuries and possibly acute illnesses related to altitude including dizziness, nausea, fatigue, cerebral and pulmonary edema, and cognitive impairments which may affect sense of balance, physical coordination, and ability to follow instructions and can increase the risk of accidents;
  • Injuries related to facilities including falling snow or ice;
  • Injuries related to failure or malfunction of my own or others’ equipment or improper equipment use;
  • Injuries caused by my own actions or negligence and/or the actions or negligence of other people;
  • Injuries or illnesses related to manmade objects such as barbed wire, other fences, vehicle and foot bridges, building remains, and garbage or other junk;
  • Illnesses related to preparation or consumption of food, including undercooked food, and water, including untreated or improperly treated water;
  • Injuries related to vehicles or travel in vehicles; and
  • Illnesses that are contagious, including COVID-19.

I voluntarily accept these risks along with any and all similar risks.

I understand that there is a risk of becoming lost or separated from companions or program facilitators/chaperones by traveling in urban or forested areas, over rugged terrain, or during bad weather.

I understand that accidents, illnesses, or injuries may occur in remote places where medical facilities are not readily accessible.

I understand that the description of these risks is not complete and that unknown or unanticipated risks may result in injury, illness, disability, or death.

I understand that the proper use and wearing of safety equipment can greatly reduce the risk of injury. I agree to wear and/or use appropriate safety equipment as directed by law or by Sierra STEM.

I agree to use all provided equipment and supplies as intended and as directed. I also understand that I may be held responsible for the repair or replacement of any equipment, supplies, or facilities that are lost or damaged as a result of my participation in this program.

I understand that this activity may be physically strenuous and requires a certain level of physical fitness. I am in good physical condition, can meet the rigors of this program, and have not been advised otherwise by a physician or other healthcare provider. I assume the risks for any medical conditions I may have.

I verify that, if my health markedly changes between completion of the health questionnaire and the beginning of the Sierra STEM program, I will inform Sierra STEM of these changes.

I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating in this program, or agree to bear such costs myself.

2. Release from Liability

I fully release the following persons and organizations:

a. Sierra STEM and its respective officers, directors, agents, employees, shareholders, successors, and assigns, on my own behalf as well as on behalf of my heirs, successors, and assigns

b. Any other related parties that are or may become liable for any loss or injury to me or to my property, or for my death, arising out of my participation in Sierra STEM’s programs

from any and all liability, claims, demands, or causes of action whatsoever arising out of any damage, loss, or injury to me or my property, or my death, which may occur as a result of or in the context of my participation in this Sierra STEM program, whether such loss, damage, injury, or death results from the negligence and/or other fault, either active or passive, of any of the parties described at paragraphs 2a and 2b above, or from any other cause.

3. Covenant Not to Sue

I agree never to institute any suit, action, or claim against any of the organizations and/or persons described at paragraphs 2a and 2b above, or to initiate or assist in the prosecution of any claim arising from the activities covered by this Liability Waiver, whether caused by the negligence and/or fault, either active or passive, of any of the parties described at paragraphs 2a and 2b above, or from any other cause.

I further expressly agree that I will never raise any claim against any of the parties described at paragraphs 2a and 2b above for product liability, failure to warn, negligence, breach of warranty, breach of contract, or strict liability, regardless of whether my claims for damages or injuries are alleged to result from the fault or negligence of the parties released.

I further agree that my heirs, executors, administrators, personal representatives, and/or anyone else claiming on my behalf, shall not institute any suit or action at law or otherwise against any of the parties described at paragraphs 2a and 2b above, nor shall they initiate or assist the prosecution of any claim for damages of cause of action that I, my heirs, successors, assigns, and/or anyone else claiming on my behalf may have by reason of injury to my person or property, or my death arising from the activities covered by this Liability Waiver, whether caused by the negligence and/or fault, either active or passive, of any of the parties described at paragraphs 2a and 2b above, or from any other cause, I hereby so instruct my heirs, executors, administrators, personal representatives, and/or anyone else claiming on my behalf.

Should any suit or action at law or otherwise be instituted in violation of this Liability Waiver against any of the parties described at paragraphs 2a and 2b above, I agree that such parties shall be entitled to recover, in addition to any other damages that may be incurred, reasonable attorney’s fees and costs incurred in defense of such suit or action, including any appeals therefrom.

4. Indemnity Against Claims

I agree to indemnify, defend, and hold harmless the parties described in paragraphs 2a and 2b above from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including reasonable attorneys’ fees, brought as a result of my participation in an activity offered, organized, or provided by Sierra STEM.

5. Validity of Waiver

I understand that if I institute, or anyone on my behalf institutes, any suit or claim for damages or cause of action against any of the parties described at paragraphs 2a and 2b above because of injury to my person or property, or my death, due to the activities covered by this Liability Waiver Form, this Liability Waiver form can and will be used in court, and that such waivers have been upheld in courts in similar circumstances.

6. Severability/Multiple Waivers

I agree that, should one or more provisions in this Liability Waiver be judicially determined to be unenforceable, the remaining provisions shall continue to be binding and enforceable against me. If I have executed any other liability and waiver form(s) containing provisions relating to the exemption and/or release from liability and/or covenant not to sue in connection with the activities covered by this Liability Waiver, I agree that the liability and waiver form that provides the most protection from liability and/or suit to the parties described at paragraphs 2a and 2b above shall be enforceable against me by such parties.

7. Applicable Law/Jurisdiction

This Liability Waiver is governed by and shall be construed in accordance with the laws of the state of California, without any reference to its choice of law rules. I agree that any dispute arising from this Liability Waiver or in any way associated with the programs or services offered by Sierra STEM shall be brought in the Superior Court of the County of Mono, California or in the Eastern District Court of California, and I agree to the jurisdiction and venue of those courts for any such dispute.

 

By signing this document, I acknowledge and agree that I understand the potential risks associated with participation in the activity offered or organized by Sierra STEM and voluntarily accept them. I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against Sierra STEM on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.


If Participant is under age 18 for any portion of participation in Sierra STEM’s programs:

Parent/Guardian Signature and Indemnification

In consideration of the below-named participant (“Minor”) being permitted by Sierra STEM to participate in its programs and to use associated equipment and facilities, I further agree to indemnify and hold harmless Sierra STEM from any and all claims which are brought by or on behalf of Minor and which are in any way connected with such use or participation by Minor.


Participant Health Form

Sierra STEM programs involve a variety of activities ranging in difficulty from group initiative problems to preparing food to hiking and exercising. Some programs may also include other rigorous physical adventure activities such as backpacking, cross-country skiing, climbing, paddling, or swimming. These activities are designed to be within the limits of a person who is in reasonably good health. Sierra STEM selects and designs activities in coordination with Partner Organizations to match the abilities of participants, while also aiming to push participants to grow outside of their comfort zones while remaining safe.

Accurate and Complete Information: The information requested on this form is intended to help alert staff to preexisting medical conditions. Misinformation could result in injury or illness or may compound the severity of an injury or illness. This form must be completed prior to participation in any Sierra STEM Experiential Learning program.

Privacy:

  • Health information provided here will be protected by Sierra STEM.
  • It may be shared with representatives of Partner Organizations when necessary for the health or safety of a participant.
  • It may be shared with healthcare providers in case of emergency.


Consent to Treat:

Sierra STEM has the right to give first aid to the named below, and to engage the service of a physician, emergency room, dentist, and/or other healthcare provider or to hospitalize if deemed necessary. I further authorize Sierra STEM to act as the participant’s representative in signing consent for necessary clinical or surgical procedures when the participant is not able to do so. In the event of an emergency, I will be notified as soon as possible. The cost of such service will be charged to the participant or parent/guardian and paid by the same.


Today's Date: September 20, 2024

Please select who will be participating...
Minor
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First Participant's Name

First Name*

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

Physical and Outdoor Activities:


1. Please describe any concerns you have about your participation in any of the physical activities included in this Sierra STEM program (e.g., a hike lasting up to 4 hours):

Dietary Restrictions:

2. Do you have any food allergies?*
No
Yes

If yes, please describe these food allergies and the reactions they cause:
3. Do you have any other dietary restrictions?*
No
Yes

If yes, please describe these dietary restrictions.

Medical Conditions:

4. Other than foods, do you have allergies/reactions to any: (check any/all that apply)
Medications
Plants
Insects
Other

Please provide details about any allergies/reactions you indicated above.
5. Do you have any chronic or recurring injuries OR have you had surgery in the past year?*
No
Yes

If yes to any of the above, please explain/describe:
6. Are you currently taking any medications?*
No
Yes

If yes, please provide details about each of these medications. For each medication, please provide: medication name, condition it treats, dosage/frequency, administration (pill, injection, etc), and whether it is self-administered.
7. Do you have any of the following conditions? (check any/all that apply)
Asthma
Diabetes
Epilepsy
Heart Condition
Allergies that require me to have an Epi Pen with me

If yes to any of the above, please explain/describe:
8. Do you have a history of any of the following conditions? (check any/all that apply)
Vasovagal syncope or other fainting episodes
High blood pressure
Heart palpitations
Chest pain or pressure
Heart attack
Heart disease
Heart murmur
Stroke
Seizure
Medical implants or devices of any kind

If yes to any of the above, please explain/describe:

9. Please describe any other concerns or conditions that you or your doctor feel may affect your participation in Sierra STEM’s programs. If you ran out of space answering any of the above questions, you may continue your answers here:

We strongly recommend that you consult your physician before participation in Sierra STEM’s programs, especially if you have any of the conditions above.

Participant Image and Likeness Release

I agree to release any images of myself/participant by means of photography or videography while I am a participant in any of Sierra STEM’s programs or while I am a client of Sierra STEM. Sierra STEM may use the above-mentioned images without limitation in connection with any brochure, website, social media, publicity, marketing, or educational materials.

I understand that Sierra STEM reserves the right to use the names of the program you are participating in (e.g., Brain Camp), along with any participant's first name and last initial in conjunction with any of the above-mentioned images.

I release Sierra STEM from any claims whatsoever which arise in said regard.



First Participant's Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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(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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Physical and Outdoor Activities:


1. Please describe any concerns you have about your participation in any of the physical activities included in this Sierra STEM program (e.g., a hike lasting up to 4 hours):

Dietary Restrictions:

2. Do you have any food allergies?*
No
Yes

If yes, please describe these food allergies and the reactions they cause:
3. Do you have any other dietary restrictions?*
No
Yes

If yes, please describe these dietary restrictions.

Medical Conditions:

4. Other than foods, do you have allergies/reactions to any: (check any/all that apply)
Medications
Plants
Insects
Other

Please provide details about any allergies/reactions you indicated above.
5. Do you have any chronic or recurring injuries OR have you had surgery in the past year?*
No
Yes

If yes to any of the above, please explain/describe:
6. Are you currently taking any medications?*
No
Yes

If yes, please provide details about each of these medications. For each medication, please provide: medication name, condition it treats, dosage/frequency, administration (pill, injection, etc), and whether it is self-administered.
7. Do you have any of the following conditions? (check any/all that apply)
Asthma
Diabetes
Epilepsy
Heart Condition
Allergies that require me to have an Epi Pen with me

If yes to any of the above, please explain/describe:
8. Do you have a history of any of the following conditions? (check any/all that apply)
Vasovagal syncope or other fainting episodes
High blood pressure
Heart palpitations
Chest pain or pressure
Heart attack
Heart disease
Heart murmur
Stroke
Seizure
Medical implants or devices of any kind

If yes to any of the above, please explain/describe:

9. Please describe any other concerns or conditions that you or your doctor feel may affect your participation in Sierra STEM’s programs. If you ran out of space answering any of the above questions, you may continue your answers here:

We strongly recommend that you consult your physician before participation in Sierra STEM’s programs, especially if you have any of the conditions above.

Participant Image and Likeness Release

I agree to release any images of myself/participant by means of photography or videography while I am a participant in any of Sierra STEM’s programs or while I am a client of Sierra STEM. Sierra STEM may use the above-mentioned images without limitation in connection with any brochure, website, social media, publicity, marketing, or educational materials.

I understand that Sierra STEM reserves the right to use the names of the program you are participating in (e.g., Brain Camp), along with any participant's first name and last initial in conjunction with any of the above-mentioned images.

I release Sierra STEM from any claims whatsoever which arise in said regard.



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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