RELEASE AND INDEMNIFICATION AGREEMENT AND EMERGENCY CONTACT FORM Student Name * First Name Last Name Student Address Address 1 Address 2 City State/Province Zip/Postal Code Country Student Email * School ID Number * Student Phone # * (###) ### #### Description of Activity and or Trip * Mode of Transportation * Start Date of Trip * The Conference Starts on Jan 26,2024 MM DD YYYY End Date of Trip * The Conference Starts on Jan 28,2024 MM DD YYYY I, the above named student, am eighteen years of age or older and have voluntarily applied to participate in the above Activity or Trip. I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks that may result in my illness, personal injury or death and I understand and appreciate the nature of such hazards and risks. In consideration of my participation in the Activity or Trip, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release HAVEN Student Fellowship, its governing board, officers, employees and representatives from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Activity or Trip, whether caused by negligence of the HAVEN Student Fellowship, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the HAVEN Student Fellowship and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described Activity or Trip. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. * (PLEASE TYPE YOUR NAME BELOW IF YOU AGREE) I do hereby authorize HAVEN Missions, and those acting under its authority to: 1. Record my participation and appearance on videotape, audiotape, film, photograph or any other medium. 2. Use my name, likeness, voice, and biographical material in connection with these recordings. 3. Exhibit or distribute such recording in whole or in part without restrictions or limitation for any educational or promotional purpose which The University of Texas, and those acting under its authority, deem appropriate. * (PLEASE TYPE YOUR NAME BELOW IF YOU AGREE) Name of Nearest Relative * First Name Last Name Address of Nearest Relative * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of Primary Doctor If you don't have one, please put N/A First Name Last Name Phone # of Primary Doctor (###) ### #### Health Insurance Company If you don't have one, please put N/A First Name Last Name Health Insurance Policy Number * Health Insurance Phone # (###) ### #### Allergies Current Medication Thank you!
