Registration Seventh Conference
Release Form
I*EARN - Fourth INTERNATIONAL YOUTH SUMMIT
The China Hall of Science and Technology - Beijing, China
WAIVER AND RELEASE PARTICIPANT INFORMATION
NAME:___________________________________________ SCHOOL:___________________________________________ ADDRESS:___________________________________________ CITY:_____________________________ STATE/PROVINCE:______________________ COUNTRY:___________________________________________ Date of birth: ________________(month/day/year) Age: _______ Sex/Gender: ________
__________________________________ ___________________________________
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 take every precaution 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 Beijing, China 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:
I do hereby release and forever discharge I*EARN from any and all actions, liability, claims or demands for or by any reason of damage, loss or injury which may be sustained by my child as a result of his/her participation in the I*EARN International Youth Summit.
__________________________________________________ _________________
Signature of parent/legal guardian .......................................................Date
CONSENT AND RELEASE FORM
I hereby grant to I*EARN, 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, 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 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
Please return this form by fax to: 86-10-6865 5091 or by mail to:
Seventh International Conference of I*EARN
Subude-I*EARN China, Zhong Guan Cun
Post Office Box #106, Haidian District,
Beijing, China 100080
