ESCAPE will NOT administer or provide medications. It is your responsibility to supply and provide your own medication. I understand that I must provide and supply my own medications:blank*
ESCAPE will NOT provide transportation. It is your responsibility to drive and/or coordinate transportation to and from ESCAPE. I understand that I must provide and supply my own transportation. However, if transportation is provided I agree to waive all liability to the SCATMTF: blank*
ESCAPE will NOT provide medical treatment or medical assistance. If a medical emergency arises ESCAPE will call an ambulance and you will be taken to a medical facility. blank*
ESCAPE will NOT allow assault, theft, or other inappropriate behaviors. I agree to abide by the Zero Tolerance Policy and Agreement. blank*
The following will NOT be tolerated and will result in immediate expulsion and/or further consequences including or not limited to law enforcement and prosecution:
ESCAPE Retreat by the Sickle Cell Association of Texas Marc Thomas Foundation adheres to a strict Zero Tolerance Policy. Participants will be required to leave the premises and not allowed to return to future programming if any of the violations above occur.
I, blank* understand that I, the ESCAPE participant, will be responsible for any items that I break or damage while at the ESCAPE Retreat/Camp for All. I understand that if I breach the Zero Tolerance Agreement I can face immediate expulsion, legal prosecution, and/or be not allowed to return to future programs.
(Initial here)blanks*ADDITIONALLY, I UNDERSTAND THAT COMPLETING THIS APPLICATION DOES NOT NECESSARILY MEAN I WILL BE ACCEPTED INTO THE ESCAPE RETREAT. FACTORS INCLUDING FUNDING, CERTAIN CIRCUMSTANCES, AND/OR SPACE WILL DETERMINE IF I AM ACCEPTED.
I acknowledge and understand this agreement between the Sickle Cell Association of Texas Marc Thomas Foundation and myself. By signing this agreement, I acknowledge, accept, and agree to adhere to their Zero Tolerance Policy and Agreement.
I,blanks* give permission for the Sickle Cell Association of Texas Marc Thomas Foundation (SCAMTF) to take and use any photographs/videos of me including the use of my name, for general promotional purposes now or in the future in keeping with the general goals of the Association.
I agree that photographs and/or videos taken of me including transparencies, negatives, prints, electronic versions and products thereof, may be used by the SCAMTF in a legitimate manner for educational program development and/or promotion including but not limited to fundraising, donor appeals, website usage, brochures, pamphlets, flyers, presentations, outreach, advocacy, education, sponsorship information, media and literature. By signing this document, I agree that I am granting the SCAMTF the right to exhibit the photo/video images for the aforementioned purposes.
PARTICIPATION CONSENT: I, blanks*, the ESCAPE Retreat participant authorize my participation in ESCAPE RETREAT by the Sickle Cell Association ofTexas Marc Thomas Foundation (“ESCAPE”), including all related activities. I fully understand all of the dangers, hazards, and risks that are associated with and may occur as a result of my participation in ESCAPE and related activities. These activities include, but are not limited to, the activities of horseback riding, high and lowelements ropes course, swimming, archery, riflery, sporting activities, canoeing, and other camp-related activities. I understand that these activities are voluntary and I have familiarized myself with the ESCAPE Program and activities at Camp For All in which I will be participating. I understand that these dangers and risks may result in property damage and/or loss, impairment to health and well-being, and/or physical injury, including serious or even fatal injuries. I acknowledge that although ESCAPE and Camp For All have taken safety measures to minimize the risk of injury to participants, ESCAPE and Camp For All cannot insure or guarantee that the participants, equipment, premises, or activities will be free of hazards, accidents, or injuries. I recognize and willadhere to the importance of knowing and abiding by the rules, regulations, andprocedures for ESCAPE at Camp For All. I also agree to inform ESCAPE of anyactivities in which I may not participate.
2. EXCULPATORY AND INDEMNITY CLAUSE. In consideration of being permitted to participate in the ESCAPE I agree to assume full responsibility for all risks. I further agree to release, waive, agree to hold harmless and covenant not to sue the ESCAPE Retreat, and all purposes the Sickle Cell Association of Texas Marc Thomas Foundation a non-profit agency, and its board of directors, officers, agents, employees, volunteers, and Camp For All (referred to collectively as "Releasees"), from and against any and all liability, claims, demands, actions, causes of action, suits in equity, whatsoever arising out of or related to any loss, damage, loss of property, or injury, including fatal injuries along with court costs and attorney’s fees and expenses whether caused as a result of sole, joint or concurrent negligence, negligence per se, statutory fault or strict liability of releases or otherwise, that may be sustained while participating in ESCAPE and ESCAPE related activities while in or upon the premises where the ESCAPE and related activities are being conducted or while being transported to, from or in connection with the ESCAPE. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. I further agree to indemnify the Releasees from liability, claims, demands, actions, causes of action, or suits in equity arising out of loss, damage or injury that occurs as a result of my negligent or intentional act or omission while participating in the ESCAPE and in related activities. 3. NO INSURANCE. I understand that Releasees may or may not maintain any insurance policy covering any circumstance arising from my participation in ESCAPE or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. ESCAPE and SCAMTF may not carry general liability insurance to cover claims arising from ESCAPE and ESCAPE activities so it seeks a waiver of claims as additional consideration for the right to participate so ESCAPE and the SCAMTF, can (a) provide the ESCAPE to most participants; and (b) to provide access to a greater number of participants by expending limited resources on program materials and activities rather than on liability insurance. 4. MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and WAIVER. I understand Releasees cannot be expected to control all of the risks articulated in this form and Releasees need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at an off-site medical facility or hospital, during my participation in this activity with the understanding that the cost of any such treatment will be my responsibility. I agree to indemnify and hold harmless Releasees for any costs incurred to treat myself, even if Releasees has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. I further agree to release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes, Releasees from any and all liabilities, claims, demands, injuries (including fatal injuries), or damages, including court costs and attorney’s fees and expenses, that may be sustained by myself while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries sustained as a result of sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of Releasees. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. 5. BINDS HEIRS. It is my express intent that this Release, Waiver, Indemnification, and Agreement not to Sue shall bind myself, the other members of my family and spouse, if I am living, and my estate, family, heirs, administrators, personal representatives, or assigns, if I am not living. 6. AGREEMENT OF RELEASE AND VOLUNTARY SIGNATURE: In signing this Release, Waiver, Indemnification and Agreement not to Sue, I acknowledge and represent that I have carefully read the document and understand its contents and that I sign voluntarily as my own free act and deed. ESCAPE and Releasees have not been made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this agreement. I further state that I am at least eighteen (18) years of age and fully competent to sign; and that I have executed this Release for full, adequate, and complete consideration fully intending to be bound by the same.
PLEASE READ CAREFULLY BEFORE SIGNING.
By signing below you agree to the terms of the Waiver, Indemnification, and Agreement not to Sue and agree to follow all instructions and procedures in order to maintain safety while attending ESCAPE Retreat.
I understand that the cost to participate in ESCAPE Retreat is $50 which can be paid within this application or with a check mailed to 314 E. Highland Mall Blvd. Suite 411, Austin, Texas 78752. This application is not considered complete without payment. If accommodations are needed please contact us at email@example.com.