Medical Consent, Release and Assumption of Risk - online version for NON USA citizen/resident only!

Medical Consent, Release and Assumption of Risk - online version for NON USA citizen/resident only!

International Field Studies, Inc.
This online version of the medical consent form is only for IFS Participants that are not citizens/residents of the United States of America. All US citizens/residents that visit Forfar, or participate in an IFS Trip, must submit a notarized paper version of this form found on the registration page.*

I am NOT a citizen/resident of the USA
Country of Citizenship/Residence*
Participant's Name*

First NameLast Name
As used herein: “FIELD STUDY DIRECTORS” shall include International Field Studies, Inc., its officers, directors, employees,
staff, and school/group* (associated school/group), it’s teachers, agents, employees, and licensees.
“UNDERSIGNED” shall be the father and/or mother, or the guardian of the PARTICIPANT, or the PARTICIPANT if eighteen years of age
or older.
The UNDERSIGNED understand that during the field study under the direction of the FIELD STUDY DIRECTORS, certain risks and dangers may occur, including, but not limited to, hazards, accidents or illness of any kind whether foreseeable or unforeseeable, the forces of nature, and travel by airplane, automobile, bus, train, or other conveyance. The UNDERSIGNED understand that many activities associated with the field study and related activities may take place in remote places without medical facilities.

In consideration of the right to participate in this field study and related activities and to utilize the services, including food, as provided, the UNDERSIGNED hereby assume all risks, including those set forth above, and hereby hold the FIELD STUDY
DIRECTORS harmless from any and all liability, actions, causes of actions, debts, claims and demands of every kind and nature whatsoever whether foreseeable or unforeseeable, which arise from or in connection with the above described field study and related activities. This release and assumption of the risk shall apply to the negligent acts or omissions of the FIELD STUDY DIRECTORS. The terms hereof shall serve as a release and assumption of the risk for the UNDERSIGNED, his or her heirs, executors, administrators, and members of the UNDERSIGNED’s family.

In the event emergency medical treatment is required for the PARTICIPANT while the PARTICIPANT is under the control and direction of the FIELD STUDY DIRECTORS, and if consent is a requisite to any such treatment, the UNDERSIGNED hereby grants to the FIELD STUDY DIRECTORS the right to give consent for such treatment for the PARTICIPANT on behalf of the UNDERSIGNED. Said consent may be granted or withheld by the FIELD STUDY DIRECTORS as each of them, in their sole direction, shall determine. The UNDERSIGNED hereby waive any and all claims, which they may have against the FIELD STUDY DIRECTORS arising from the granting or the withholding of the aforesaid consent.

In the event that emergency medical treatment is provided to the PARTICIPANT, the UNDERSIGNED hereby authorizes FIELD STUDY DIRECTORS and/or any other entity providing medical services or material in conjunction with emergency medical treatment to the PARTICIPANT, to seek payment for said services or material and assigns any medical, insurance benefit for same services or material to International Field Studies, Inc. from the following insurers of the PARTICIPANT
Insurance company name:*
Policy number:*
The UNDERSIGNED hereby guarantees payment of any medical insurance deductible, any service not covered by PARTICIPANT’s insurer, or any other cost incurred in providing emergency medical treatment, to International Field Studies Inc., and/or
any other entity providing or paying for medical services or material in conjunction with emergency medical treatment.
The Undersigned and Participant below have read the Medical Consent, Release, and Assumption of Risk and hereby voluntarily agree to the same, and have answered all the questions on the Medical History Form (separate sheet), to the best of her or his ability:
Signature*

Clear
Should be Empty: