8th I*EARN International Teachers' Conference
Release Form
5th I*EARN INTERNATIONAL YOUTH SUMMIT : DISCLAIMER AND INDEMNITY
University of Cape Town, Cape Town, South Africa
WAIVER AND RELEASE PARTICIPANT INFORMATION
NAME:__________________________________________________________________
SCHOOL:________________________________________________________________
ADDRESS:_______________________________________________________________
CITY:_____________________________ STATE/PROVINCE:______________________
COUNTRY:_______________________________________________________________
Date of birth: _________________ (month/day/year) Age: _______ Sex: Male / Female
Name of parent/legal guardian ____________________________________________________________
Relationship to participant _______________________________________________________________
Address of parent/legal guardian __________________________________________________________
____________________________________________________________________________________
Telephone number of Parent/Guardian: ____________________________________________________
Person to contact in case of emergency if different from parent/legal guardian ______________________
Relationship to you ______________________ Telephone number ______________________________
MEDICAL RELEASE
Please list any allergies to medication:
List any other allergies:
List any significant illnesses, injuries, or emotional conditions about which the sponsors should be aware:
HEALTH CARE - I*EARN will not provide health care of any kind for participants. Any health needs which might arise are the responsibility of the participants and their guardians. For purpose of both your protection and ours, we would like to know your insurance company (if applicable) and your policy number in case of an emergency.
Insurance company: _______________________________________________
Policy number: ___________________________________________________
Please sign to signify your responsibility for your own health and well-being at the I*EARN meeting.
__________________________________________________ _________________
Signature of youth participant.................................................................. Date
I hereby understand and agree to the above:
__________________________________________________ _________________
Signature of parent/legal guardian......................................................... Date
GENERAL RELEASE FORM FOR MINORS
The I*EARN International Youth Summit encompasses a select group of young people from various nations of the world. There may be occasions in which audio tape, videotape, or photographs (or all three) are taken for either a news story or as part of the material record of the meeting.
I*EARN assumes that by giving your child permission to attend the meeting you are fully aware of the nature of the meeting, the schedule, and basic content. We further assume that you are supportive of your child's participation. While we will strive to maintain schedules and timetables, some of the sessions may go late or start early. Your child is responsible for attending every session of the meeting.
I*EARN will use its best efforts to maintain a safe and secure environment in which the world of the Youth Summit can be conducted. The members of I*EARN will do it's utmost to provide your child with a rewarding experience. Part of the I*EARN International Youth Summit may include travel around the host city region and its environments. During those sessions, members of I*EARN will provide specific instructions designed to maintain the decorum of the entire group. We are not responsible for any other transportation arrangements.
In consideration of your child's acceptance into the I*EARN International Youth Summit, please read and sign the following:
In my capacity as parent and/or legal guardian of the minor child named above ("the participant"), I hereby :
- Agree that neither I*EARN nor its sponsoring organisations (namely the Western Cape Schoolsı Network, SchoolNet SA and the University of Cape Town) will be liable in any way whatsoever for any loss or damage which may be suffered by the participant or any other person as a result of or arising in any way out of any harm or injury which may befall the participant, or the loss or destruction of, or damage to, any property owned by the participant or in the participantıs possession, which occurs during the course of or in relation to or in connection with the participantıs participation in the 5th I*EARN International Youth Summit, or the participant being conveyed to or from any Summit venue, activity or residence, irrespective of how or by whom any such harm, injury, loss, damage or destruction may be caused.
- Indemnify and hold harmless I*EARN and all the sponsoring organisations referred to above, against any claim which may be made against I*EARN and/or any of those sponsoring organisations, by any person, arising from or relating to any harm, injury, loss, damage or destruction contemplated above, including but not limited to any claim which may be made by the heirs, parents, guardians, dependants, executor, administrator or trustee of the participant."
__________________________________________________ _________________
Signature of parent/legal guardian .......................................................Date
CONSENT AND RELEASE FORM
I hereby grant to I*EARN and it's sponsoring organisations, the absolute right, for as long as often as they may elect, to copyright and/or use and/or publish in video, audio, print, or any other media, my name and/or likeness and/or statements, in whole or in part, for purposes of public education and information. I grant these rights in perpetuity for use in news, education, art, or any other lawful purpose whatsoever.
I waive any right to inspect and/or approve any related products which may be developed by I*EARN or the use(s) to which they may be applied. I also hereby release I*EARN and it's sponsoring organisations, from any and all claims relating to or arising from the uses consented to above. I understand that under no circumstances shall I have any right to maintain any cause of action against I*EARN and any of the sponsoring organisations by virtue of this agreement, the use of my name, likeness, and/or statements, or anything done pursuant here to.
I have read this consent and release form, fully understand its contents, and agree to its terms knowingly and voluntarily.
__________________________________________________ _________________
Signature of youth participant................................................................. Date
I hereby understand and agree to the above:
__________________________________________________ _________________
Signature of parent/legal guardian............................................................Date
8th I*EARN International Teachers' Conference
AFRICA CONNECTS Conference Organisers
Telephone: +27 21 674-9140
Fax: +27 21 683-6766
E-mail: info@ac.wcape.school.za
Web: http://ac.wcape.school.za
Post:
PO Box 44460,
Claremont 7735,
Cape Town, SOUTH AFRICA
Physical address:
Cape Town Teachers' Centre,
Molteno Road,
Claremont 7735
Cape Town, SOUTH AFRICA
