Student Medical Information Form - Short Page 2

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Teton Science Schools, Inc.: Acknowledgment And Assumption Of Risks &
Release And Indemnity Agreement
(Adult and child participants – SHORT FORM)
INTRODUCTION
Please read this entire Acknowledgment and Assumption of Risks & Release and Indemnity Agreement (hereafter 'Document') carefully
before signing. All participants 12 yrs. of age or older must sign this Document. For participants under 18 yrs. of age (hereafter
sometimes 'minor' or 'child'), one or both parent/s or legal guardian/s (hereafter collectively 'parent/s') must also sign and parent/s may
print the name (instead of a signature) for those participants under 12 yrs. of age. In consideration of the services of Teton Science Schools,
Inc., and its officers, directors, employees, representatives, agents, volunteers, independent contractors and all other persons or entities associated
with it (collectively referred to in this Document as ‘TSS’), I (participant and parent/s of a minor participant) acknowledge and agree as follows:
ACKNOWLEDGMENT AND ASSUMPTION OF RISKS
TSS educational and/or adventure and recreation activities on or off TSS premises (which may be scheduled or unscheduled, supervised or
unsupervised or occur during free time), including those offered through the variety of TSS programs, may include, but are not limited to: hiking;
nature walks; wildlife viewing; canoeing; bird banding; handling animals; avalanche or other course instruction and travel in trams, chairlifts or other
means or in vans, buses and other vehicles (collectively referred to in this Document as 'activities'). Participants may engage in these activities
independently or as conducted by TSS staff or contractors. I acknowledge that the inherent and other risks, hazards and dangers of these
activities can cause injury, property damage, illness, mental or emotional trauma, paralysis, disability or death to participant or others.
Some, but not all of these risks include travel in high-altitude, mountainous or wilderness terrain; unpredictable and hazardous ground, water or
weather conditions, including uneven terrain and extreme air or water temperatures; exposure to burns or sunburns; misjudgments made by TSS
staff, contractors or others; close and unpredictable contact with wildlife; allergic reactions or injury from plants or stinging, venomous or disease
carrying animals or insects; the potential that the participant or others (e.g. co-participant, driver, medical or rescue personnel) may act carelessly or
recklessly; personal health risks (disclosed or undisclosed, known or unknown) and equipment that can be misused or can fail or malfunction. I
understand that TSS staff members or contractors cannot assure my safety or eliminate any of these risks. Parent/s of minor participants agree to
discuss the nature of these activities and risks with their child. During both supervised and unsupervised activities, all participants share in the
responsibility for their own safety and agree to follow all TSS rules and policies. Participant is voluntarily participating with knowledge of the
risks. Therefore, participant (and parent/s of minors) assumes and accepts full responsibility for the inherent and other risks (both known
and unknown) of these activities and for any injury, damage, death or other loss suffered by participant (and parent/s of minors), resulting
from those risks and/or resulting from participant's negligence or other misconduct.
RELEASE AND INDEMNITY AGREEMENT
Please read carefully. This Release and Indemnity Agreement contains a surrender of certain legal rights. Certain federal land agencies
(including the National Park Service and some regions of the U.S. Forest Service) restrict service providers, including TSS, from seeking releases of
liability for negligence, for injuries or other losses occurring while operating under permit or concession on those federal lands. Therefore, except to
the extent a court determines these federal restrictions are enforceable against TSS as a matter of law, I (adult participant or parent/s for
themselves and for and on behalf of their participating minor child) agree as follows:
1) to release and agree not to sue TSS with respect to any and all claims, liabilities, suits or expenses (including attorneys’ fees and costs)
(hereafter collectively 'claim' or 'claim/s') for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or
participation in these activities or use of TSS equipment, facilities or premises. I understand that in signing this Document, I, my child and
anyone acting on my or my child’s behalf, surrender all rights to make a claim against TSS as a result of any injury, damage, death or
other loss suffered by me or my child;
2) to defend and indemnify ('indemnify' meaning protect by reimbursement or payment) TSS with respect to any and all claim/s brought by or on
behalf of me, my child, spouse or other family member, a co-participant or any other person for any injury, damage, death or other loss in any way
connected with my/my child's enrollment or participation in these activities or use of TSS equipment, facilities or premises.
This Release and Indemnity Agreement includes claim/s resulting from TSS’ negligence (but not its willful or wanton misconduct), and
includes claim/s for personal injury or wrongful death (including claim/s related to emergency or medical response, assessment or
treatment), property damage, breach of contract or any other claim.
CONCLUSION
I (participant and parent/s of a minor participant) agree that Wyoming substantive law (without regard to its 'conflict of laws' rules) govern this
Document, any dispute I have with TSS and all other aspects of my relationship with TSS and that any mediation, suit or other proceeding must be
filed or entered into only in Teton County, Wyoming. I agree to attempt to settle any dispute (that cannot be settled by discussion) through mediation
before a mutually acceptable Wyoming mediator. I authorize TSS staff, representatives, contractors or other medical personnel to obtain or provide
medical care for participant, to transport participant to a medical facility and to provide treatment they consider necessary for participant’s heath. I
agree to pay all costs associated with that care and transportation. I agree to the release (to or by TSS) of any medical records necessary for
treatment, referral, billing or insurance purposes. I authorize TSS to use my or my child's photo or image in any manner for advertising, display,
audiovisual, electronic or other use. This Document is intended to be interpreted and enforced to the fullest extent allowed by law. If any
portion of this Document is deemed unlawful or unenforceable it shall not affect the remaining provisions, and those remaining provisions
shall continue in full force and effect.
Participant and parent/s of a minor participant agree: I have carefully read, understand and voluntarily sign this Document, and
acknowledge that it shall be effective and binding upon me, my minor children, spouse and other family members and my heirs,
executors, representatives and estate. One or preferably both parent/s must sign below for any participating minor (those under 18 yrs. of
age).
__________________________________________________________________________________________________________________________________________ _________
Participant Signature (parent/s may print name for those participants under 12 yrs. old)
Date
Print Name Here
Parent 1
/ Parent 2
Parent or Legal Guardian Signature
Date
Print name here
/ Parent or Legal Guardian Signature
Date
Print name here
Short Risk Release Form 6/1/06

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