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Men's Sanga
Camp Ignite
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Resources
Donate
Contact Us
Get in Touch
TSI Gita nagari 2022 Retreat Liability Release Form
Name
*
(Attendee)
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Insurance Number
*
Put N/A if no insurance
In case of Accident or Injury, Notify
*
Relationship to Attendee
*
Parent
Aunt
Uncle
Grandparent
Sibling(18 or older)
Other
*If other specify
Phone #
*
Person being notified
(###)
###
####
Swimming Ability
*
Non-Swimmer
Needs Supervision
Good Swimmer
Medical Information
Bee Sting Allergy
*
Mild
Moderate
Severe
List Nut Allergies:
*
Other Allergies
*
Allergies (Can you care for your own allergies?)
Yes
No
Medications :
*
Medication (Can you take your own medicine?)
*
Yes
No
N/A
List any health problems:
*
List any restrictions to activities due to health:
*
List any foods or ingredients you cannot eat: (all food served is Vegetarian Krishna Prasadam)
*
Contract of release and Assumption of Risk Agreement:
In an emergency, you will be transported to the nearest emergency hospital. Please note we will not administer medications of any kind. Please make sure tetanus immunization is up to date. I realize that all recreational activities have inherent risks. I knowingly accept and assume this risk and agree to release The Sanga Initiative from any liability and responsibility. Further I agree to indemnify and hold harmless The Sanga Initiative and the volunteers from any and all claims, damages, injuries and expenses arising out of or resulting from my participation in all activities and transportations to said activities. I have read the release and assumption of risk agreement and agree to be bound by it.
Acknowledgment of Understanding:
The undersigned have read this assumption of risk release and waiver of liability, and indemnity agreement, and have had the opportunity to ask questions about the same. The undersigned fully understand this assumption of risk, release and waiver of liability and indemnity agreement, that the undersigned are giving up substantial rights in connection therewith, and that its terms are contractual, and not a mere recital. The undersigned acknowledge that they are signing this agreement freely and voluntarily.
*
I acknowledge that I am signing this agreement freely and voluntarily, and I further confirm understanding of all pre-stated terms and conditions under Contract of Release and Assumption of Risk Agreement & Acknowledgement of Understanding.
Name
*
Participant
First Name
Last Name
Electronic Signature
*
Ex. /s/Tom Ford
Date of Electronic Signature
*
MM
DD
YYYY
Thank you!
