INTERNATIONAL LEADERSHIP OF TEXAS

Transcription

1 INTERNATIONAL LEADERSHIP OF TEXAS ACKNOWLEDGMENT OF RISK, INDEMNITY, WAIVER AND RELEASE OF LIABILITY AGREEMENT, NOTICE OF FINANCIAL RESPONSIBILITY, AND MEDICAL AUTHORIZATION & INFORMATION FORM IN WITNESS WHEREOF AND BY SIGNING BELOW, I/WE APPROVE TRAVEL FOR MY/OUR MINOR CHILD AS FOLLOWS: Student s full legal name must be written EXACTLY as it appears on his/her passport. Last Name First Middle DOB/Age Hair (Color) Eyes (Color) Height Name of Student s School Destination Country Trip Dates With (Traveling Adult s Full Legal Name) Home Address Passport Number Issued by State DL/ID Number Telephone Alternate Emergency Contact Relationship Telephone Alternate Acknowledgment of Risk I/we, acknowledge that International Leadership of Texas (ILTexas) that ILTexas cannot protect my/our child from risks which may be encountered during this international travel ( the Trip ). I/we realize there are human, natural, mechanical, and environmental conditions and hazards which independently, or in combination with my/our child s activities may cause a serious accident resulting in death, injury, personal property loss, health conditions or financial expenses as a result of accident, illness, medical care, political upheaval, terrorism, crime, transportation, or other sources of risk. I/we hereby state that I/we understand these inherent risks and dangers involved with participation in the Trip and its associated activities, and further acknowledge that some or all of these risks are not obvious or predictable. 1

2 Indemnity, Waiver and Release of Liability Agreement In consideration for my child being permitted to participate in the Trip, as the natural or adoptive parent and/or as the legally authorized guardian, I do hereby for myself, my spouse, my child, and on behalf of my/our heirs, personal representatives, and assigns, agree not to sue and hereby release, waive, discharge, hold harmless and indemnify and forever defend ILTexas and its officers, directors, employees and volunteers, individually and collectively ( the protected parties ), from any and all liability, losses, claims, actions, suits, procedures, demands, rights, and causes of action of whatever nature, in law and equity, for any and all known or unknown, foreseen or unforeseen, bodily or personal injuries, death and permanent injury, illnesses, damage to property, or other losses, and any consequences thereof, including expenses, costs, and attorney s fees, as may be sustained by my child or me arising out of or in any way associated with my child s participation in the Trip, its related events and activities or travel incident thereto, whether by negligence, INCLUDING THE NEGLIGENCE OF THE PROTECTED PARTIES, or not, to the fullest extent permitted by law. Initials The risk of serious injury to my child from the Trip does exist, including the potential for permanent disability and death. I understand and fully acknowledge that my child s participation in the Trip is solely at our own risk and I assume full responsibility. Initials Notice of Financial Responsibility Please note that the ILTexas reserves the right to delay, reschedule or cancel any trip for safety or other reasons, and third parties may cause it to be delayed, rescheduled or cancelled for reason s beyond ILTexas s control. In the event of such a delay, rescheduling or cancellation, the Trip operator s cancellation policies, as well as those of the hotels, airlines, ground transportation companies, ticket operators and others providing services in connection with the Trip will determine the amount of any refund to which you are entitled, if any. Refunds or any other reimbursements will not be provided by ILTexas if the trip is delayed, rescheduled or cancelled. By signing below, parents and guardians acknowledge that they have read this notice and accept responsibility for any and all cancellation fees, costs, or losses. I/WE HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW AND UNDERSTAND THE CONTENTS THEREOF. I/WE SIGN THIS RELEASE VOLUNTARILY AS MY OWN FREE ACT WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE, INTENDING TO BE LEGALLY BOUND THEREBY. Signature of Parents/Guardians Legal Mother Printed Name Signature 2

3 Legal Father Printed Name Signature Legal Guardian Printed Name Signature Date Telephone Alternate [REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK] 3

4 Authorization for Emergency Medical Treatment In case of accident, illness, or other emergency, I/we request that International Leadership of Texas ( ILTexas ) personnel contact me. If the ILTexas personnel cannot reach a parent/guardian after conscientious effort, I/we give permission for ILTexas personnel to call emergency service providers or medical or dental service providers. If a life-threatening emergency exists, I/we give permission for ILTexas personnel to immediately call emergency personnel and then contact me/us as soon as possible thereafter. In the event that I/we cannot be reached to give necessary medical consent, I/we the undersigned grant permission for ILTexas to arrange for all necessary emergency care for our child. We will be financially responsible for such care and for emergency medical transport. I/we authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care, which, in the best judgment of a licensed physician or dentist, is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. Student s Medical Information Health Insurance Carrier Policy # Under the name of Relationship Name of Family Physician or Pediatrician Phone Number(s) ( ) Attach a photocopy of a current insurance card. Is there a known history of: Circle One A. Contact lens or glasses YES NO B. Medical conditions currently under treatment YES NO C. Preexisting injury currently under treatment YES NO D. Fractures of other disability type injuries YES NO E. Allergy (drugs, food, asthma, etc.) YES NO F. Seizure disorder or convulsions YES NO G. Medication currently being taken YES NO Explain above questions answered yes. Medicine must be in original container, with directions for administrator of medicine. 4

5 Child s Name: Are there any other physical or medical conditions we should know about? (Attach extra page if needed) Signature of Parents/Guardians Legal Mother Printed Name Signature Legal Father Printed Name Signature Legal Guardian Printed Name Signature Date Telephone Alternate [REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK] 5

6 PERMISSION FOR MINOR TO TRAVEL AFFIDAVIT I/We: and Parent or Guardian Printed Name Parent or Guardian Printed Name Understand that my/our child: Student s full legal name must be written EXACTLY as it appears on his/her passport: Last Name First Middle DOB/Age Hair (Color) Eyes (Color) Height Will be travelling as follows, with International Leadership of Texas Charter School: Destination Country Trip Dates With (Traveling Adult s Name EXACTLY as it appears on his/her passport) Relationship with child: As the child s Parent(s) or Guardian(s) I/we swear to truth of the contents of this document, and its attachments and give full consent to this international travel. Signed and Address Telephone Alternate Alternate Date 6