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PO Box 303

June Lake CA 93529

760-428-9512 

info@sierrastem.org

Participant Agreement, Liability Waiver, and Assumption of Risk

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:

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.

The activities in any Sierra STEM program depend on the program in which I (or my child) is enrolled. I understand and accept that there are inherent risks associated with outdoor or outdoor skill-building activities, which can include, but are not limited to: hot or cold weather injuries or illnesses; injuries from natural disasters like storms or earthquakes; drowning; falling or tripping on snow, ice, or rocks; injuries from obstacles hidden by snow or ice; injuries related to climbing or falling on rocks, like broken bones or death; injuries related to hiking, like blisters or bruises; injuries from falling like concussions; injuries or illnesses related to altitude; injuries caused by the failure or malfunction or misuse of equipment; injuries from manmade objects or equipment; illnesses related to preparation or consumption of food; injuries related to vehicle travel; and contagious illnesses.

I understand that there is a risk of becoming lost or separated from companions or program facilitators/chaperones; that accidents, illnesses, or injuries may occur in remote places where medical facilities are not readily accessible; that the description of these risks is not complete and that unknown or unanticipated risks may result in injury, illness, disability, or death, and that Sierra STEM staff may not give complete warnings for every activity or risk; 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; that this activity may be physically strenuous and requires a certain level of physical fitness.

I agree to use all provided equipment and supplies as intended and as directed, and 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 verify that, if my health 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.

I hereby release, indemnify (meaning to pay or reimburse for expenses), and hold harmless, Sierra STEM from any and all claims, demands, losses, and liability related to any injury, illness, property damage, disability, or death, I, my child, or any other person may cause or suffer related to my (or my child’s) participation in the program or the use of any equipment or facilities. This release and indemnity includes any claims related to the negligence of Sierra STEM  and is to be interpreted to the fullest extent allowed by law. I fully acknowledge and assume both the inherent risk and responsibility for claims caused by my (or my child’s) negligent acts and omissions. I consent to the use of any photographs or video taken of me (or my child) or provided by me (or my child) to be used for publicity, promotion, television, websites, or any other use, and expressly waive any right of privacy, compensation, copyright, or other ownership right connected to this use. I agree that any dispute I have (or my child has) with Sierra STEM will be governed by the laws of the state of California and that any suit, arbitration, mediation, or other claims must be brought only in the state of California. If any portion of this agreement is deemed unenforceable, the remaining parts of the agreement will continue to remain in full force and effect. 

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.



First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent or Guardian's Email Address
Email*
Confirm Email*
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*
Middle Name
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Dietary Restrictions
Does your child have any food allergies or dietary restrictions? *
No
Yes
If yes, please list the allergen and the reaction in the box above.
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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