Tatra Mountain Cultural Foundation 7434 W. 61st PI Summit, II. 60501
Tel. (708) 772-6600 Email: firstname.lastname@example.org
Participant's Agency Name and Policy # blanks (nazwa agencji ubezpieczeniowej i numer ubezpieczenia)
Purchased for the time period of the event (ubezpieczenie wykupione na czas wyjazdu) From (Od): blanks To (Do): blank Insurance Name (Nazwa Ubezpieczenia) : Ubezpieczenie na czas trwania kolonii mozna wykupić bezpośrednio W Travel Insured, Tel.: (800)243-3174, www.travelinsured.com, lub W innej preferowanej przez państwo agencji ubezpieczeniowej.
IDENTIFICATION AND ACKNOWLEDGEMENT OF RISKS
I understand, that Tatra Mountians Cultural Foundation program primarily conducted in the outdoors. Camp activities such as, but not limited to, swimming, soccer, basketball, volleyball fishing, using air guns, horseback riding, rock climbing, wilderness travel, ropes courseactivities, lake/river activities, skiing, climbing walls, biking, backpacking, hiking, airplane rides, transportation to and from the activity site, and many others may result in property damage or fatal injury. Dangers also inherent to lakes & rivers, forces of nature such as darkness, heavy rain, lightning, strong winds, extremes of heat and cold, biting insects and animals may cause an accident or serious injury. I understand that although Tatra Mountians Cultural Foundation with Camp Vista together has taken reasonable precautions to provide proper equipment, suitable facilities, and trained staff, it is impossible to guarantee totally negligence free environment, absolute safety against illness, injury, or loss resulting from participation. I acknowledge the risk inherent in camp program and agree to assume that risk.
ASSUMPTION OF PERSONAL RESPONSIBILITY
Icertify,that participant have no communicable diseases. I will notify the Tatra Mountain Cultural Foundation in writing of any medical or emotional condition that may restrict safe participation in the program. I inform, that above named participant (if under the age of 18) will not have any telecommunication devices like cell phones, 2-way radios etc. I acknowledge that participant failure to adhere to safety rules established by the Tatra Mountain Cultural Foundation may result in being asked to discontinue participation in the program. If participant is barred from further participation, or if I and/or participant voluntarily refrain from participation, or if I and/or participant leave thetrip, I am responsible for all expenses incurred and I have no claim for any refunds from the Tatra Mountain Cultural Foundation and its representatives.
AUTHORIZATION FOR MEDICAL TREATMENT
of In case of an emergency, I hereby give permission to the Tatra Mountain Cultural Foundation representatives and/or groupleaders organization who organize the event to secure medical treatment that might include hospitalization, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for participant named above. I also certify that my insurance company or myself will cover all accidental, medical and transportation costs.
In consideration of participating in any activities in any event organized by the Tatra Mountain Cultural Foundation, I herby agree to release and discharge from liability the Tatra Mountain Cultural Foundation and its owners, directors, officers, employees, agents, volunteers, participants, and all other persons or entities acting for them on behalf of myself and my children, parents, heirs, assigns, personal representative and estate. Consequently, I waive, release, and discharge any and all claims for any personal injury or damages, death, or property damage/loss, which I may have as a result of participation. I understand that the Tatra Mountain Cultural Foundation shall not be liable for any delay or accidents of means of transportation arranged by the Tatra Mountain Cultural Foundation any and all acts of a third parties, or any other cases beyond their control. the Tatra Mountain Cultural Foundation reserves the right to cancel, change, or substitute any service because of weather, safety condition of activity places/equipment, insufficient number of participants or other reasons. My registration provides the Tatra Mountain Cultural Foundation the authorization to use photos and videos of me or registered participants for promotional purposes without further consent or compensation.
I am aware, that I am responsible for paying all participant's medical expenses and related costs for any injuries that may occur during participation in the event. I agree to maintain throughout my participation, sufficient medical and accidental insurance (insurance should be valid in the State of Wisconsin I understand that this is my sole responsibility to release all persons and entities from providing this coverage for participant. the Tatra Mountain Cultural Foundation strongly recommend to purchase a TRAVEL INSURANCE to protect against the risk of medical expenses, death, travel delays, trip cancellation, any damage, loss of baggage or personal belongings, etc.
I understand and accept all terms and conditions presented to me in the English language. (Rozumiem i akceptuje wszystkie warunki i zasady przedstawione mi W jezyku angielskim)