Participation Authorization, Informed Consent, Release of Liability, and Medical Treatment Consent

12/21/2015

Girl Scout University – Alpha Phi Omega, Alpha Rho Chapter

I hereby certify that I have read and fully understand the nature and scope of the event as proposed on this web site, and further understand the potential risks inherent in such activities and participation as described on this website, and/or in meetings with adult leaders.

I therefore agree to and accept the rules and guidelines and to furnish and wear or use any required safety equipment specified or suggested for participation in the activity as described on this web site.

(FOR THOSE UNDER AGE 18, PARENTAL/GUARDIAN CONSENT REQUIRED AS FOLLOWS):

I authorize participation by my child or children that I am representing (“Girls”) in the activity described on this web site, and consent to supervision of my Girls adult advisors/leaders during this event.

I understand that normal safety procedures and leadership guidelines will be implemented during this activity.

I further recognize that certain risks may be inherent in the conduct and participation in this activity that may be beyond the control of adult leaders and/or activity sponsors.

I further certify that I and/or my Girls is/are medically and physically capable of participation in this event and is/are medically cleared by a physician for participation in such activities.

In recognition of the benefits derived by myself and/or my Girls, and in the event of any accident resulting in injury, illness, disability, or death, or property loss or damage, which might occur to myself and/or my Girls while traveling to or from or during the conduct of this event, I agree to indemnify, agree not to sue, and agree to hold harmless, the Girl Scouts of Central Texas; Girl Scouts of America; the Alpha Rho Chapter, Alpha Phi Omega, National Service Fraternity; the Regents of The University of Texas, a Body Corporate; event sponsors, instructors, advisors, leaders, volunteers, other event participants, and any or all agents, employees, representatives (or their executors or heirs) acting on behalf of such organizations or individuals, from all claims damages, losses, injuries and expenses arising out of or resulting from participation in these activities.

I further agree to release, acquit and covenant not to sue the aforesaid parties, including the drivers of vehicles transporting my Girls for any and all actions, causes of action, claims or damages, damages in law or remedies in equity of whatever kind, including the negligence of the aforesaid parties.

I agree the site of any lawsuit and the law governing any such lawsuit shall be Texas and governed by Texas state law.

The terms of this agreement shall continue and be in effect after the activity has ended.

As liquidated damages, I hereby agree that if the Girl Scouts of Central Texas; Girl Scouts of America; the Alpha Rho Chapter, Alpha Phi Omega, National Service Fraternity; the Regents of The University of Texas, a Body Corporate; or any of the individuals or organizations named hereon is forced to defend any action, lawsuit or litigation initiated by myself, my executors, or my heirs, on my family’s or my behalf, I and/or my heirs or executors agree to pay the Girl Scouts of Central Texas and any or all such organizations or individuals named hereon, any costs and attorney’s fees incurred if they successfully defend such action, lawsuit, or litigation.

Photo Release

I hereby assign and grant to the Alpha Phi Omega, Alpha Rho Chapter and the Girls Scouts of America, the right and permission to use and publish the photographs/electronic or sound recordings made of me this date by the Girl Scouts of America and Alpha Phi Omega, Alpha Rho Chapter, and I hereby release the Girl Scouts of America and Alpha Phi Omega, Alpha Rho Chapter from any and all liability from such use and publication.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage and/or distribution or said photographs/film/video tapes/electronic representations and/or sound recordings without limitation at the discretion of the Girl Scouts of America and Alpha Phi Omega, Alpha Rho Chapter and I specifically waive any right to any compensation I may have for any of the foregoing.

Off Facility Release

I give the permission to Alpha Phi Omega, Alpha Rho Chapter and the Girl Scouts of America to take my scout off the facilities used during Girl Scout University to an off-campus facility for the sole purpose of class instruction.

Medical Treatment Consent

In the event of injury or illness to myself and/or my Girls, I consent to administration of such first aid measures as may be determined necessary by activity leaders, and if determined necessary, I further consent to transport by ground or air ambulance and/or referral to physicians and admission to hospitals.

I further consent to emergent medical treatment for myself and/or my Girls if determined necessary, including but not limited to, anesthesia, injection, surgery, x-ray, and medication, if I cannot be contacted immediately for such consent. I understand that reasonable efforts will be made to contact me in such cases. I understand that reasonable efforts will be reached during this event is listed here.