Dear Applicant, Registration Requirements and Criteria. The application process consists of the following steps:

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1 Dear Applicant, Welcome to ETA Expedition Therapy! We are committed to admitting students who will contribute to and feel supported by our wilderness expedition experience. Our application process is an opportunity for you to become empowered as you move forward towards positive change in your life. We appreciate you taking the time to complete these pages as we hope to get to know you in advance of your arrival. The Admissions & Clinical Team will read each application personally and we look forward to getting to know you and your life journey. Please feel free to contact the office at anytime with any questions that you might have. Registration Requirements and Criteria The application process consists of the following steps: You will be completing this enrollment packet, which includes: Registration Form, personal history and story, treatment history and record release, written agreement, waiver, consent for exam/treatment, photo release, insurance info, authorization for emergency costs and a Power of attorney. We want to know about your interests, your struggles, your goals, hopes, and dreams and other information you choose to share. Your parents or Sponsor will be asked to help you and sign for you when you complete the Enrollment Application which includes student and family contact information, your educational and medical histories, as well as their perspective on your past behavior and current level of functioning. You will be asked to sign release forms that give us permission to request records from previous programs or professionals who have worked with you in the past. The Admissions & Clinical Team will review all the information received from you and your parents or Sponsor to determine if you could benefit from the ETA Expedition Therapy Program. When the Admissions & Clinical Team determines that you meet the admission criteria of young adults who enroll at ETA Expedition Therapy, the Team may also want to schedule a phone call to speak with you regarding any questions and concerns you may have prior to enrollment and to learn more so you feel at ease upon admission. Once the Admissions & Clinical Team decides you are admitted, you and your parents/sponsors will also be asked to make a decision to enroll. You will need to sign a few additional documents. If you have any questions regarding how to complete the forms in this packet or require additional information about ETA Expedition Therapy Program or admissions process, please, contact us at info@expeditiontherapy.com or by phone at Expedition Therapy Associates 110 E Red Shadow Lane, Kanab, UT

2 Registration Form Name: Date of Birth: Gender: Height: Weight: Shoe size: Pants size: Shirt size: Starting Date: Program name/length (8 week program/capstone/custom): Mailing Address: Phone # s: Home Cell Work General state of health / fitness level: What are your expectations for this course? In case of emergency notify: Phone #: Address: A deposit is required to reserve your space on an ETA course, and the remaining balance is due 90 days prior to course departure. We accept personal or cashier s checks, most major credit cards, and wire transfers. Amount enclosed: $ How did you hear about Expedition Therapy? Why did you choose ETA Expedition Therapy Program? Travel and Accommodations: Please contact us with special travel and/or accommodation information. Arrival City: Date/Time: Airline/Flight #: PARENT INFORMATION: Father's Name: Home Phone: Address: City: State: Zip: Social Security #: Cell: Work Phone: DOB: 2 PARENT INFORMATION: Mother's Name: Home Phone: Address: City: State: Zip: Social Security #: Cell: Work Phone: DOB:

3 PERSONAL AND SOCIAL HISTORY Participants Name: Over the next few pages are some questions to help ETA Expedition Therapy get to know you better. Please answer each question as completely and openly as possible and remember that there is no right or wrong answers. This information will be kept confidential and is privileged information unless you are threat to yourself/ others and or if physical and or sexual abuse has been disclosed. 1. Briefly explain why you are applying to ETA Expedition Therapy. Was it your decision to apply? Yes No Please include any situation or challenge you are currently facing. 2. What do you experience as the major obstacles/challenges confronting you currently? 3. What strategies/techniques have you used to manage these obstacles/challenges, and what results have you experienced? 4. Please give us a brief history of the development of your current challenges or situation. 5. What goals are you trying to achieve through your participation in this program? 3

4 6. What is likely to happen in your life if you do not choose to complete this program at this time? 7. Please list your significant relationships: Name: Relationship: Occupation: 8. Please describe your relationships with your family members: 9. How do you think your family would describe you? 10. How do you think your friends would describe you? 11. Are you adopted? Yes No If yes, please describe your relationship with your birth parents: 12. Please describe your current living situation. With whom, for how long? Relationship to person/people: 4

5 13. Please describe your strengths: 14. Please identify some specific areas you would like to focus upon and to improve: 15. Have you experienced any traumatic events or losses?: 16. Have you ever attempted or discussed suicide? No Yes If yes, please explain: 17. Have you ever demonstrated violence towards yourself or others? Yes No If yes, please describe the situation, specific behaviors and date: 18. Do you ever experience severe isolation? If so, please explain: 19. Have you ever demonstrated sexual acting out? If so, please explain: 5

6 20. Do you have any legal issues pending? If so, please explain: 21. Do you have an attorney or public defender? If so, please supply their name and contact information: 22. Have you ever been diagnosed with a psychological condition? Yes No if yes, please explain. 23. Are you currently taking any medication for said conditions? If so, please list. 24. Using the scale below, please check the box that best describes your drug and alcohol use: No use Experiment Monthly Weekly Daily For How long? Tobacco Alcohol Cannabis (marijuana) Amphetamines (speed, crystal meth) Cocaine (Crack) Hallucinogens (PCP, LSD, mushrooms Inhalants (gas, glue, nitrous oxide) Opiates (Heroin, Demerol, Oxycontin, Percoset, Derion) Sedatives (sleeping pills) Club Drugs (ecstasy, Special K) Steroids Other Please add any further information you feel we would find helpful regarding the above 25. Do you smoke or otherwise use tobacco Yes No ETA does not allow smoking in the field. If you do smoke, do you intend to use nicotine patches to assist with withdrawal? If yes, please bring an adequate supply with you before arrival. 6

7 EDUCATION: 1. What was the last school you attended? 2. What was the highest grade you completed? 3. Please describe any behavior or academic difficulties you have experienced in a school setting: VOCATIONAL: 1. Have you ever been employed? Yes No. If yes, please briefly they type of job you held, duties performed and your reason for leaving if not still currently employed. 2. Do you have a profession that you are interested in pursuing? Yes No. If yes, please explain. 3. Have you ever been enrolled in the military? Yes No. If yes, please let us know within which branch and your capacity while enrolled. You may use this space to give us any further information you feel would give us a greater insight into you and your personality. 7

8 TREATMENT HISTORY Name of Participant: TREATMENT HISTORY: Please list your most recent programs, counselor and or therapists. List any other facility and or professional you might want treatment history from. Name: Name: Name: Name: Name: Phone: Phone: Phone: Phone: Phone: ETA Expedition Therapy Program - RELEASE OF INFORMATION The following professionals and/or institutions, who have counseled, treated, or educated (participant), are hereby authorized to release all information regarding medical/treatment history, diagnosis, disability, and/or school records to ETA Expedition Therapy Program, staff and/or consultants who will be involved in the participant s program. Name of Institution or Clinic: Dates of Treatment: Contact Name: Phone: Fax: Name of Institution or Clinic: Dates of Treatment: Contact Name: Phone: Fax: Name of Institution or Clinic: Dates of Treatment: Contact Name: Phone: Fax: Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) 8

9 ETA EXPEDITION THERAPY PROGRAM WRITTEN AGREEMENT Provider: ETA Expedition Therapy program Student (Parent / Guardian) printed name: If the participant is a minor the agreement will be signed / initialed by parent of guardian This agreement is made effective as of this day of 20, by and between the above listed parties. In this agreement; the party who is agreeing to receive services will be referred to as I/we. The party providing the services, ETA Expedition Therapy Program and its officers, directors, employees and agents will collectively be referred to as ETA Expedition Therapy. 1. IDENTIFYING INFORMATION I/we, (participant/sponsor), enter into this contract with ETA for the purpose of securing placement in ETA Expedition Therapy Program and clarifying the rights and responsibilities of each party. (initial and date) 2. ELIGIBILITY AND ACCEPTANCE I/we understand that said participant must meet ETA Expedition Therapy Program eligibility requirements for acceptance into programming, and that misrepresentation of participant for this purpose potentially places this participant at great risk and may result in discharge from ETA Expedition Therapy Program. I/we further understand that part of the screening process is completed in the first week of programming, and agree that ETA Expedition Therapy may determine at this time that said participant is clinically or medically inappropriate for placement. If participant is discharged at this time I/we agree to pay for the return trip home or for travel expenses to another placement. I/we understand that we will be charged only for the days (any time spent at ETA Expedition Therapy on any day is counted as a full day) that participant is enrolled. 3. SERVICES PROVIDED AND FEES/COSTS I/we agree services provided include: airport transfers, food, lodging, and group equipment (tents, sleeping bag, sleeping pads, backpack and technical equipment). Educational hands-on curriculum that includes: teaching skills, Leadership and technical skills, group dynamics, self awareness, astronomy, geology etc. Rock Climbing, Canyoneering, Mountaineering, Backpacking and wilderness experiences with challenging adventure activities. Individual and group therapeutic sessions and continued therapeutic support for family and consumer. This deposit is non- DEPOSIT: A $250 deposit is required in conjunction with application for admission. refundable however, if accepted, it does apply to the total program cost. PAYMENTS: We accept personal checks, cashier s checks, money orders, wire transfers, and Visa and Master cards. The following payment terms apply upon acceptance into the ETA Expedition Therapy program. Initial 35 days of Expedition Therapy - $13,825 due prior to or upon enrollment. If purchasing the equipment package for $1,250 this is due upon acceptance so that we can ensure all items are available upon arrival. Remaining 21 days of Expedition Therapy - $8,295 due on day 35 Additional weeks after initial 8 weeks are billed in 2-week increments unless other arrangements are made in advance. Any extensions of stay require payment in full within one week upon confirmation of extension. All extensions are arranged in 7 day increments. 9

10 MINIMUM LENGTH OF STAY: ETA Expedition Therapy has a variety of programs including Capstone courses and custom expedition that have unique lengths. For the general Expedition Therapy program, students must enroll for a minimum of five weeks (35 days), however, we strongly recommend an eight week stay (56 days). 3. SERVICES PROVIDED AND FEES/COSTS - CONTINUED FROM PREVIOUS PAGE (initial and date) REFUNDS: In the event that you are unable to join us the following guidelines will apply. We strongly recommend travel insurance for all participants. The $250 registration fee is non-refundable. If student is required to leave due to medical or clinical reasons, ETA Expedition Therapy will issue a full refund for remaining days already paid for after deducting fees for services rendered. No refunds will apply for early departure not associated with medical or clinical reasons. 50% refunds will be provided if student/sponsor decides not to participate in the program after initial registration fee and deposit have already been paid. 4. COSTS OF PROGRAM AND COLLECTION OF COSTS Failure to pay may result in the participant being sent home immediately at participant s expense. I/we will not hold ETA Expedition Therapy responsible for any consequences that result from the participant s premature discharge and participant remains liable to pay for any and all costs incurred to that date. I/we agree to pay all costs and expenses incurred in collection of any past due amounts, including court costs and attorney s fees whether incurred prior to or subsequent to any litigation. I/we also agree to pay finance charges of 12% APR as outlined on the financial page of this application. 5. LOST OR RUNAWAY EXPENSES Any costs incurred by the participant if he/she runs or gets lost from ETA Expedition Therapy and expenditures made by ETA Expedition Therapy in the pursuit of the participant will be paid by the participant/sponsor. ETA Expedition Therapy will make every reasonable effort to find the participant in as quickly a manner as possible. I/we hereby release, hold harmless and indemnify ETA Expedition Therapy from any and all liability arising out of or resulting in the participant running away or getting lost while enrolled, except any liability arising out of ETA Expedition Therapy s intentional actions or gross negligence. 6. TRAVEL TO AND FROM THE PROGRAM I/we agree to make arrangements for and pay in full for participant s travel to and from ETA Expedition Therapy. I/we agree that any such arrangements will be made by participant/sponsor and that ETA Expedition Therapy will have no responsibility or culpability for any travel to ETA Expedition Therapy, or any events which may occur including running. ETA Expedition Therapy wholly independent of any hotels, transportation companies, land operators and suppliers of travel or other services (other than those provided directly by ETA Expedition Therapy and its employees) that may be used in connection with the trip or expedition. ETA assumes no responsibility or liability in connection with the operation or service of any aircraft, motor vehicle, other conveyance, inn, lodge, hotel or services provided by any independent contractor or service provider which may be used wholly, or in part, for services to ETA Expedition Therapy and its clients, and will not be responsible for any act, error, omission, nor for any injury, loss accident, delay, inconvenience, irregularity or damage which may be occasioned in conjunction with any such services. 7. POWER OF ATTORNEY I/we agree to the stipulations in the Power of Attorney, for the duration of the participant s enrollment with ETA Expedition Therapy by signing the Power of Attorney included in the enrollment application. 10

11 8. GOVERNING LAW This Contract shall be construed in all respects in accordance with the laws of the State of Utah, without regard to conflicts-of-laws principles that would require the application of any other law. 9. AUTHORIZATION AND CONSENT FOR ELECTRONIC COMMUNICATIONS I authorize ETA Expedition Therapy to transmit personal communications from the participant by posting on a secure (password-protected) web-page, to be arranged after the participant s arrival at ETA Expedition Therapy. I understand that errors may occur in the transmission of personal communications between participant and sponsor. I release ETA Expedition Therapy from any and all liability for errors in the transmission of participant s personal communications. I agree to keep confidential the nature of any communication that I may receive in error and to notify ETA Expedition Therapy, immediately. (initial and date) I hereby grant permission for my assigned therapist (initial and date) and/or my Education Consultant (initial and date) to read mail and see photos posted to the secure web page. I understand and give permission for my group photos to be posted for all families in the participant s group. These images remain passwordprotected from all others. 10. SEVERABILITY If any provision of this Contract will be held to be invalid or unenforceable for any reason, the remaining provisions will continue to be valid and enforceable. If a court finds that any provision of this Contract is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision will be deemed to be written, construed, and enforced as so limited. 11. NOTICE Any notice or communication required or permitted under this Contract shall be sufficiently given if delivered in person or by certified mail, return receipt requested, to the address set forth in the opening paragraph or to such other address as one party may have furnished to the other in writing. 12. FAMILY INVOLVEMENT I/we understand that ETA Expedition Therapy may request parents/families/sponsor to be enrolled and participating in Family Therapy. (initial and date) In the event that consultation between ETA Expedition Therapy and the family therapist is relevant to the treatment of the participant, please provide your Family Therapist contact information. Family Therapist: Phone #: 13. PARTICIPANT RESPONSIBILITY Course participants are responsible for their own well-being. This includes good health and physical condition. Participants joining a course are required to obtain a physician's release prior to departure. Course members are responsible for: knowing all pre-departure information, preparing proper equipment and clothing, conforming to basic standards of personal hygiene (to minimize the risk of travelers diseases) and acting in a considerate manner toward all group members. Participants are prohibited from using illegal drugs, nicotine and alcohol while on ETA Expedition Therapy courses. Participant's responsibilities further include the following: (1) they are responsible for reviewing the various forms, releases, and information contained in the web site and forms; (2) they will follow the instructions and directions of instructors and expedition leaders. (initial and date) 14. PARTICIPATION COMMITMENT I/we understand that the program is a demanding physical and emotional experience and agree that the participant will participate in and accept stressful physical and mental challenges as being part of the treatment experience. Completion of the ETA Expedition Therapy will be determined by the therapist, based on clinical and wilderness progress. The participant agrees to participate in all clinical and wilderness activities. (initial and date) 11

12 15. MEDICAL INSURANCE ETA Expedition Therapy requires that all students have their own health insurance. Individuals are solely responsible for any medical costs, including all associated rescue, evacuation, and transportation costs. Please take time to review your medical insurance policy. Make certain that your coverage extends to the location of your course, and that it provides coverage for any potential, associated, costs. Many policies will provide coverage for travel abroad for a small additional fee. _ 16. CONDITIONS OF LAND BASED COURSES ETA reserves the right to change the price of, cancel or withdraw any course for any reason whatsoever prior to departure. After departure, ETA reserves the right to alter or omit any part of the itinerary, to substitute accommodations, instructors or clinicians, to change any means of conveyance without notice and without allowance of refund, with liability for increased costs (if any) borne by the course members. ETA reserves the right to accept or reject any person as a course participant at any time. I understand, and am aware, that during the course in which I am currently participating, or will participate in, under the arrangements of ETA Expedition Therapy, certain risks and dangers may arise including, but not limited to: altitude; steep or treacherous terrain; inclement weather; avalanches, rock fall and other natural occurrences; exposure to sun, strong wind, cold temperatures, storms, and lightening; misuse, failure or loss of equipment; shortage of food or water supply; aggressive and/or poisonous wildlife; the forces of nature; acts or omissions of ETA Expedition Therapy; travel by boat, automobile, train, ship, aircraft or other means of conveyance; and accident or illness in remote places without access to medical facilities, transportation, or means of rapid evacuation and assistance; risks associated with running away from the program. I certify that I am familiar with the dangers, hazards and risks incident to trekking, mountaineering, rock climbing and canyoneering as listed above. And I accept and clearly understand that these hazards and risks may result in personal injuries to me and others, including paralysis and death, and hereby expressly assume all of the above risks including, the risks of acts or omissions of ETA and do hereby expressly agree to hold ETA harmless and defend them against any and all liability. In consideration of the services furnished me, and to be furnished me as a member of this course, I hereby release ETA Expedition Therapy and all the members of the course from any and all damages, injuries, losses, or any cause of action which may result to me, my legal representatives or others purporting to exercise statutory or other rights arising out of, or in connection with this course. And I hereby assume each and every damage incident to my participation, and agree to indemnify and hold harmless ETA and all members of the course against any sums which they or any of them may be subject to pay in consequence of any claim. Please initial below to verify that you have read and understand the above Conditions of Land Based Courses. Signature: Print Name: Date: Parent or Guardian s Additional Indemnification (Must be completed for participants under the age of 18) In consideration of (print minors name) ("Minor") being permitted by ETA Expedition Therapy to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless ETA Expedition Therapy from any and all Claims which are brought by, in respect to or on behalf of Minor, and which are in any way connected with such use or participation by Minor. I hereby certify that I have the authority to sign on behalf of the minor, and that I and the minor have discussed the activity and the terms and conditions of this course policies form. Parent or Guardian: Print Name: Date: 12

13 CONSENT FOR EXAM AND TREATMENT I/we give permission to ETA Expedition Therapy Program to provide medical, hospital, dental, or psychiatric attention in the event of injury or illness, and to provide emergency first aid as needed, in the field until such care can be reached. I/we understand that all costs of medical care and medication needed while the Participant is enrolled at ETA are my/our responsibility. I/we understand that an initial physical exam must be provided and if not provided I/we give ETA Expedition Therapy Program permission to provide it (at cost). I/we authorize any professionals who have provided treatment to the Participant to release information to ETA. I/we are obligated to provide medical insurance for Participant and must provide proof of such prior to the beginning of the expedition. Participant Signature: Print Name: Date: Parent or Guardian: Print Name Date: (If a minor) The following service will incur additional charges if not addressed before admission: Required Immunization Tetanus Date: Tetanus Immunization must be within last 10 years. If not current, participant must be immunized. If participant objects to this immunization, a written release and waiver will be required. Prescription Eyewear: Yes/ No If yes, please bring with you. Dental Retainer: Yes/ No If yes, please bring with you in a container PERMISSION TO TEST I hereby give permission, with prior consent, for ETA Expedition Therapy to administer tests, which are pertinent and appropriate. These may include psychological, academic or medical. Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) 13

14 MEDICATION AND DOSAGE In an effort to coordinate you or your child s medication administration, it is necessary for you to complete this section. This form allows ETA Expedition Therapy to fill the medications that the Physician has prescribed in a timely manner without delaying the administration. (Please indicate what medications currently taking. ETA Expedition Therapy program will inventory meds and follow physicians instructions for distribution until reviewed with the attending Physician. After admission, permission will be obtained from you and or your physician prior to starting any new medication (Except in an emergency situation) and will expedite the process in obtaining and administrating medication for you or your child. Medication and dosage you are currently taking Medication and amount you are bringing onto expedition. I hereby authorize ETA to continue the medication myself/child is currently taking. Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) 14

15 PHOTO/MODEL RELEASE I do hereby grant ETA the right and permission to use, publish, and/or sell at ETA Expedition Therapy s discretion my photograph, voice, and/or video image for promotion of ETA Expedition Therapy and ETA-related programs and organizations. I understand that no monetary compensation exists unless informed differently in writing. Usage encompasses, but is not limited to, newsletters, printed publications, radio recordings, internet and web sites, advertising, and video or audio presentations. I hereby waive any and all rights to inspect or approve the finished product or the advertising text that may be used in connection therewith or the use to which it may be applied. I forever release, discharge, and agree to hold ETA Expedition Therapy and its affiliates, officers, directors, employees, and agents harmless from any liability by virtue of any use whatsoever of said photographs or images. Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) Name & Date of Expedition: 15

16 INSURANCE FORM ETA Expedition Therapy requires that all students have their own health insurance. Please complete this form so that we will have information concerning your insurance coverage. It is your responsibility to make sure your insurance will cover you for the duration of the course. The student will be responsible for obtaining any necessary pre-administration review. Student s Name Social Security # Birth Date Course Date No Participant will go on a course without health insurance coverage. If you do not already belong to a regular health program, we suggest a short-term policy which you may buy from your local insurance agent. Please attach an ENLARGED photocopy, front & back, of the following: 1. INSURANCE CARD, 2. PRESCRIPTION/PHARMACY CARD (if applicable) (This allows ETA Expedition Therapy Program to refill your child's prescription as needed) Name and address of person under whose name the policy is carried Name Street Address ( ) City, State Zip Phone Insurance Company Information Name Group Number Policy Number Agreement Number Address Where Claims Must Be Submitted Name Street Address ( ) City, State Zip Phone If Group Insurance, Give Group Name (employer, union or association through which the student is insured) NAME 16

17 AUTHORIZATION FOR INCIDENTAL AND EMERGENCY COSTS In the event that you leave a trip early for any reason you are responsible for all associated costs and expenses. This includes but is not limited to transportation by: car, truck, boat, plane, and/or, helicopter; medical emergencies; evacuation; and hotels and meals for yourself and any ETA Expedition Therapy employee that may accompany you during an evacuation. Travel insurance is required for all international courses and highly recommended for domestic courses. I, the participant, recognize that I am responsible for any costs associated with leaving a trip / course early for any reason. This includes but is not limited to transportation, hotels, and meals for yourself and any ETA employee that may accompany you during an evacuation. I understand that travel insurance is required for all international courses and highly recommended for domestic courses. I, the participant also recognize that required field gear and equipment can sometimes be lost and or damaged. In the event of damaged and or lost gear that needs to be replaced ETA Expedition Therapy program will supply the needed equipment and I, the participant will be responsible for replacement costs. In the event that my personal or travel insurance does not cover a rescue and all related costs or lost or damaged personal gear, I herby authorize the Expedition Therapy Associates to: (please check one of the options below) use my credit card on file to cover any and all related costs and expenses. use a credit card that I will provide over the phone to cover any and all related costs and expenses. (Credit card information must be submitted before the course start date.) Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) 17

18 ETA EXPEDITION THERAPY POWER OF ATTORNEY In this Power of Attorney Agreement and the Contract for Services, the party who is contracting to receive services will be referred to as the Participant. The party providing the services, Expedition Therapy Associates, will be referred to as ETA Expedition Therapy. I,, (the participant or parent /guardian if a minor of ), do hereby guarantee to ETA Expedition Therapy that I am the legal attorney-in-fact for the participant. I hereby execute this Power of Attorney in order that ETA Expedition Therapy may provide treatment and residential care for said participant. I grant the following powers of attorney to ETA Expedition Therapy in order that proper care may be given to said participant: 1. To thoroughly search the personal belongings and person of said participant upon arrival to the program, and during the program if deemed necessary and to confiscate any inappropriate items (considered to be illegal or harmful). 2. Physical restraint may be used if the participant is a danger to self or others, as determined by ETA Expedition Therapy personnel. Any use of physical force will be documented by the participant involved, as well as all witnesses. 3. To procure and/or provide emergency medical, hospital, psychiatric and dental treatment should such be deemed necessary for said participant as determined by ETA Expedition Therapy representative and/or Medical Director. 4. Administer drug screen, pregnancy, and other relevant medical testing. 5. Allow my participation in all program activities, knowing that such activities carry an inherent risk of injury or illness. 6. Restriction of access to telephone calls, visitors, and any deliverable materials. I execute this Power of Attorney on this day of, 20, effective upon arrival at ETA, on day of, 200. This Power of Attorney shall be in effect until completion of the ETA Expedition Therapy program unless terminated by early withdrawal from the program. Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) 18

19 SUBMISSION OF REGISTRATION FORM The registration forms may be signed and returned to ETA Expedition Therapy by mail or similar means to the following address: P.O. Box 285, Kanab, UT The registration and forms may also be printed, filled out, signed and returned to ETA as follows: 1. By faxing the completed and signed form to ETA at By scanning and ing the completed and signed form as an attachment to By completing and returning the registration forms, the undersigned hereby consent, represent and agree as follows: 1. That participant(s) have read and understand the documents and agree to the terms and conditions thereof. 2. That participant(s) agree to have the transaction and documents related thereto handled through electronic means, and that their completion and return of the documents constitute their electronic signature, consent and agreement. 3. That all information provided by participant(s) is true, complete and accurate to the best of participant(s) information, knowledge and belief. 4. That participant(s) agree to the preservation of the transaction and documents through electronic means, and stipulate and agree that a copy of any of the documents is as good as the original for all purposes. Information as to the retrieval of copies of records may be obtained by calling or corresponding with ETA Expedition Therapy. Participant Signature: Print Name: Date: Parent or Guardian: Print Name: Date: (If a minor) 19