RELEASE FORM FOR PHOTO/MEDIA RECORDING

Transcription

1 RELEASE FORM FOR PHOTO/MEDIA RECORDING I, the undersigned, do hereby consent and agree that the event s photographer, its employees, or agents have the right to take photographs, videotape, or digital recordings of me beginning on August 3 rd, 2016 and ending on August 7 th, 2016 and to use these in any and all media, now or hereafter known, exclusively for the purpose of a video production of the Champagne and Aishihik First Nations/ Our Voices - Shäna Däkeyi Käy Youth On Our Country Gathering. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to the event s photographer, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I also understand that the event s photographer is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to injury incurred as a result. Participant Signature Signature of Parent/Guardian

2 MEDICAL INFORMATION AND RELEASE FORM PARENT/GUARDIAN INFORMATION: MEDICAL INFORMATION: Allergies: Yes / No Phone (Home): Type: Phone (Work): EMERGENCY CONTACT INFORMATION: Name: Medication: Yes / No If Yes, Name: Phone (Home): Dosage: Family Physician: Frequency: Phone (Work): Next dosage:

3 In addition, permission is granted to administer any First Aid treatment that may be required: Participant Signature Signature of Parent/Guardian

4 PARTICIPANT CODE OF CONDUCT I will be supportive and show respect for myself and other participants I will participate and engage in the gathering and activities I will be on time for all events- being late will impact everyone I will communicate my concerns to the organizers I will turn my electronics/cellphone off or turn on vibrate when people are speaking I will do my best to use the buddy system, so no one is left out- or behind! I will celebrate the success myself and of others at the gathering I respect that the gathering is a bully free zone I respect and understand that this is an alcohol and drug free event I will be true to the land and take only what I need and use what I take! I will leave everything as I found it I WILL HAVE FUN! To Participant: We will be relying on responsible and cooperative behavior from all participants. My safety and the safety of others during the Shana Dakeyi Kay Youth On Our Country Gathering Youth Wellness Gathering will depend on it. I, (participant), acknowledge that I have been informed about the nature of the activities and the inherent risks during the Strength Within Circle Youth Wellness Gathering and I understand and realize these risks. I hereby consent to participate in this gathering. Failure to comply with the rules and regulations set forth and failure to obey all staff will result in expulsion from the gathering, at the participant s expense. Participant Signature Signature of Parent/Guardian/Chaperone

5 RELEASE AND WAIVER OF LIABILITIES TO: Champagne and Aishihik First Nations, Our Voices Gathering Organizers (which includes Champagne and Aishihik First Nations and any of their employees, agents, contractors, volunteers and associates here after referred to as the Organizers ) I am aware of the risks associated or related to participating in an outdoor gathering, which risks include but are not limited to: the proximity of medical care which may or may not be readily available; the failure to act safely or within one s own ability or to stay within designated areas; negligence of other participants and/or other persons; and negligence on the part of the Organizers or their staff. I acknowledge that I am responsible to providing all of my own tenting and outdoor equipment, including rain gear, sleeping bag, tent, appropriate foot wear and clothing and all other appropriate gear. I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE AND LOSS RESULTING THEREFROM. Please Initial: [ ] In consideration of the Organizers permitting me to participate, I AGREE TO WAIVE ANY AND ALL CLAIMS that I have or may have in the future against the Organizers, and their members, shareholders, directors, officers, employees, agents, representatives, independent contractors, subcontractors, sponsors, successors, representatives and assigns (collectively, the "Releasees ), and to release the Releasees from any and all liability for any loss, damage, expense or injury including death that I may suffer, or that my next of kin may suffer resulting from my participation in activities due to any cause whatsoever, including negligence, breach of contract, mistakes or errors in judgment, or from injuries resulting from mechanical breakdown or failure of equipment, or poor design or placement of any equipment, or breach of any statutory or other duty of care on the part of the Releasees, and also including the failure on the part of the Releasees to safeguard or protect me from the risks mentioned above. I AGREE TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES FROM ANY AND ALL LIABILITY for any damage to property of, or personal injury to, any third party resulting from my participation. Please Initial: [ ] I agree that this Agreement shall be effective and binding on my heirs, next of kin, executors, administrators, assigns and representatives in the event of my death or incapacity, and that this Agreement shall be governed and interpreted solely by the laws of the Yukon Territory, with any litigation with respect hereto to be brought solely within the exclusive jurisdiction of the courts of the Yukon Territory. Please Initial:[ ] I agree to abide by the following rules while participating: (a) I will not consume any alcohol or other substance which would impair my senses or judgment prior to or while participating. (b) I will promptly report any, unsafe situations or accidents that I become aware of (c) I will not hold the Organizers responsible for any lost, damaged or stolen personal belongings. Please Initial: [ ]

6 I HAVE CAREFULLY READ THIS ENTIRE AGREEMENT AND FULLY UNDERSTAND IT. I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS AND I SIGN IT FREELY ON MY OWN FREE WILL. Signature of Participant and older must sign) (18 years [ ] Parent/Guardian Name: : In consideration of the Organization permitting my child's to participate, I AGREE TO WAIVE ANY AND ALL CLAIMS against the Organizers, and their members, shareholders, directors, officers, employees, agents, representatives, independent contractors, subcontractors, sponsors, successors, representatives and assigns (collectively, the "Releasees ), and to release the Releasees from any and all liability for any loss, damage, expense or injury including death that my child may suffer, or that my child's next of kin may suffer resulting from my child's participation in activities due to any cause whatsoever, including negligence, breach of contract, mistakes or errors in judgment, or from injuries resulting from mechanical breakdown or failure of equipment, or poor design or placement of any equipment, or breach of any statutory or other duty of care on the part of the Releasees, and also including the failure on the part of the Releasees to safeguard or protect my child from the risks mentioned above. I AGREE TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES FROM ANY AND ALL LIABILITY for any damage to property of, or personal injury to, any third party resulting from my child's participation. Please Initial: [ ] I agree that this Agreement shall be effective and binding on my child's heirs, next of kin, executors, administrators, assigns and representatives in the event of my child's death or incapacity, and that this Agreement shall be governed and interpreted solely by the laws of the Yukon Territory, with any litigation with respect hereto to be brought solely within the exclusive jurisdiction of the courts of the Yukon Territory. Please Initial: [ ] My child understands and agrees to abide by the following rules and code of conduct while participating: (a) My child understands that his/her privileges will be revoked in the event that he/she engages in any activity deemed unsafe by the Organizers. (b) the Organizers will not be responsible for any lost or stolen personal belongings.

7 (c) My child will promptly report any unsafe situations or accidents that he/she becomes aware of. Please Initial: [ ] Parent(s) or Court-Appointed Legal Guardian(s) must sign below for any and agree that they and the minor are subject to all the terms of this document, as set forth above. I HEREBY CONSENT TO MY CHILD'S PARTICIPATION IN CHAMPAGNE AND AISHIHIK FIRST NATIONS/ OUR VOICES SHANA DAKEYI KAY YOUTH ON OUR COUNTRY GATHERING. I HAVE CAREFULLY READ THIS ENTIRE AGREEMENT AND I FULLY UNDERSTAND IT. I FREELY SIGN THIS AGREEMENT ON MY CHILD'S BEHALF AND I AM AWARE THAT BY DOING SO, I AM WAIVING CERTAIN LEGAL RIGHTS. Signature of Parent(s) (or Legal Court Appointed Guardian, for participants under 18) [ ] Parent/Guardian Name: :