Liability Release- South-Central US YP Work
Revised 4/11/2022
Acknowledgement and Assumption of Risks
I, the undersigned, hereby acknowledge that I have been advised and fully understand that my or my child’s participation in the Young Person Conference (“Conference”) organized by the South-Central US Young People Work (“SCUSYP”) may expose me to certain hazards and risks which are beyond the control of SCUSYP. These risks include, but are not limited to, serious personal injury, death, and loss of, or damage to property, exposed to or infected by COVID-19, and unpredictable environmental conditions or hazards. As a condition of my participation in the Conference, I agree to assume full responsibility for all the risks that such participation may entail. My participation is entirely voluntary, and I elect to participate with full knowledge of the inherent risks.
Initials
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Release and Indemnifications
I do hereby, in consideration of my and my child’s participation in the Conference, voluntarily elect to assume all risks of loss or damage to any property or any injury, including death, and hereby knowingly and freely release and agree to hold harmless and indemnify SCUSYP, its Directors and Officers, employees, volunteers, agents, collaborators, and sponsors from any and all liability, claims, demands or causes of action whatsoever by reason of any damage, loss, exposure, or injury or death arising out of my participation in the Conference and from any and all liability for any act or omission or negligence or strictliability in obtaining, rendering or failing to obtain first aid or any kind of emergency medical care. This Release and Waiver of Liability shall be fully binding on the spouse, family, heirs, executors, administrators, successors, and assigns of the participant. I authorize SCUSYP and its employees, volunteers, and/or agents to administer first aid and/or obtain all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. I also accept full responsibility for the payment of any expenses incurred from such medical and/or emergency care. I grant permission for SCUSYP to use photographs, including myself or my child for any of its materials (e.g., brochures, newsletters, website, social media sites, news media, etc.) without payment or any other consideration.
Initials
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Conference Participant Information
Full LEGAL name of young person or adult participating
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First Name
Last Name
Name of young person's parent/guardian (if applicable)
Parent/Guardian First Name
Parent/Guardian Last Name
Adult participant or parent/guardian’s signature
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Date
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Family Physician (enter N/A if none)
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Phone Number (enter 999-999-9999 if none)
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Use 999-999-9999 if none
Insurance Company (enter N/A if none)
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Policy Number (enter N/A if none)
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Group Number (enter N/A if none)
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Current medication, allergies, or health problems (enter N/A if none)
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