Participant Release and Indemnification Consent Form

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Student

Participant Date of Birth

Participant Release and Indemnification Consent (please check to agree)

I hereby consent to my participation and my child’s/ward’s participation in educational boatbuilding programs conducted by Chicago Maritime Arts Center, Inc. and any organizations or entities partnering with Chicago Maritime Arts Center, Inc. to offer such program (hereafter referred to as “Chicago Maritime”). I shall assume on behalf of myself and my said child/ward all risks of participation and agree to defend, indemnify and hold harmless Chicago Maritime, its directors, volunteers, employees and agents from any liability asserted by myself and my child/ward at any time, including subsequent to his/her reaching majority, including reasonable attorney’s fees and costs. I also warrant that my child/ward is physically fit and able to participate in the Chicago Maritime projects and activities.

Medical Release (please check to agree)

I hereby release any and all Chicago Maritime staff/supervisors/volunteers and program partner staff/volunteers from any and all liability in the event of any accident that may occur during the Chicago Maritime Program. I grant my permission to Chicago Maritime staff to treat my child in case of a medical emergency. If an injury warrants further medical attention, I expect every effort will be made to contact me to receive my specific authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given. In addition, I hereby give my permission to the supervising teacher(s) or staff (including volunteers) to take my child to the physician, dentist, or to the hospital if an accident or serious illness occurs during program hours and I cannot be located.

Required Medications

Other Medications

If the student requires medication, I understand that I am obligated to ensure that the medication be provided, with a note of authorization for the medication to be administered during the Chicago Maritime program. (If ordered by the student’s physician, an EpiPen must be supplied by the parents of the student.)

Emergency Contact

Phone

Relationship

Liability Photo Release for Minor Child or Children

I hereby authorize Chicago Maritime, to publish photographs taken of my minor child/children and/or myself listed below, and our first names and likenesses, for use in Chicago Maritime’ print, online, and video-based promotional/marketing materials, as well as other publications. I hereby release and hold harmless Chicago Maritime from any reasonable expectation of privacy or confidentiality for myself and the minor child/children listed below associated with the images specified above. Further, I attest that I am the parent or legal guardian of the child/children listed below and that I have full authority to consent and authorize Chicago Maritime to use their likenesses and/or first names. I further acknowledge that participation is voluntary and that neither I, nor the minor child/children, will receive financial compensation of any type associated with the taking or publication of these photographs or participation in Chicago Maritime marketing materials or other publications. I acknowledge and agree that the publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release Chicago Maritime, its employees, its contractors, volunteers, partners and any third parties involved in the creation or publication of such marketing materials and/or publications, from liability for any claims by me or any third party in connection with the use of photographs and /or videos of the minor children listed below.

By: Printed Name

Your Signature

Date

Thanks for submitting! We will be back to you shortly!