TSI Retreat Liability Release Form

*** If you are under 18 an additional Minor liability form will be sent to you for your parent/guardian to fill out and sign. A physical copy of this form must be sent to us in order for you to participate in the retreat.***

Name *
Date of Birth *
Date of Birth
Address *
Phone *
Put N/A if no insurance
Phone # *
Phone #
Person being notified
Medical Information
Bee Sting Allergy *
Allergies (Can you care for your own allergies?)
Medication (Can you take your own medicine?) *
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 *
Ex. /s/Tom Ford
Date of Electronic Signature *
Date of Electronic Signature