INSURANCE INFORMATION

Transcription

1 These forms must be completed and signed in all appropriate places by the participant, the participant s physician, and if under age 18, by the participant s legal guardian. The medical information we require is necessary in the event that a participant needs medical treatment while at ADF. Student Name ADF# Date of Birth Gender (circle one or specify): Female Male Specify Identity Permanent Address City State Zip Code Cell Phone Alternate Phone MEDICAL EMERGENCY CONTACT INFORMATION Person to contact first Backup contact Name Name Relation to Participant Relation to Participant Daytime Phone Evening Phone Daytime Phone Evening Phone INSURANCE INFORMATION ALL PARTICIPANTS OF THE FESTIVAL ARE REQUIRED TO HAVE PROOF OF INSURANCE Is the above-named participant covered by health insurance? YES NO If NO, coverage MUST be obtained before the beginning of ADF. Health insurance resources: Health Insurance Marketplace, Medicaid, and your local health insurance agency. How do you plan to obtain coverage before the start of the festival? If YES, provide the following information in order to expedite treatment and to facilitate the billing process should you need medical treatment while at ADF. Please provide a photo copy of your health insurance card (front & back). You may upload the photo copies in your application or them to forms@americandancefestival.org. Policy Holder s Name Relation to Student Policy Holder s Date of Birth Policy Holder s Occupation Policy Holder s Employer s Address Policy Holder s Address Insurance Company Name Insurance Company Address Policy/Subscriber # Plan # or type Rx Bin # Group # Deadline to submit forms: May 1,

2 Your Name (Please print) ADF# PHYSICIAN INFORMATION Please have your physician complete the following report. Your application is not complete unless your physician signs this section. Physician s Name Address Telephone Physician's Report: To the physician: Participation in the American Dance Festival involves extremely vigorous physical activity each day for long hours, sometimes under conditions of heightened heat and humidity. After an examination of the applicant named above, or a review of medical records, do you feel that the applicant can, with safety, undertake and maintain this active schedule? YES NO Please note the applicant's: Height: Weight: Does the applicant have any health challenges, allergies, asthma, special dietary needs, or any other medical, physical and/or emotional conditions that will prevent normal participation in the program or related activities? If so, please describe: Is the applicant currently taking any type of medication? If so, please list: Please list the applicant s immunization history: *Signature of physician: Date: Please note: Our staff cannot administer any medications, prescription, or non-prescription to participants. This includes over-thecounter medications like Advil or Tylenol for minor headaches or pains. If the participant will need to take medications while attending our program, they must bring the medication and assume responsibility for taking it as needed. MEDICAL TREATMENT CONSENT (Must be signed by the legal guardian for all students under age 18.) I, the legal guardian of the above-named participant, authorize the ADF staff to seek medical treatment for the participant as they see necessary at a medical facility. I consent to any x-ray, anesthetic, medical, or surgical diagnosis or treatment and hospital care subsequently deemed necessary by a licensed health care provider during the trip. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care, and that it is given to provide the staff authority to seek medical treatment, and to provide a licensed health care provider the authority to administer this treatment as s/he judges necessary to the above-named participant. I accept responsibility for payment of all services rendered; I authorize any medical facility which renders services to release medical information necessary for the processing of insurance claims; and I authorize the payment of insurance claims directly to the medical facility. I understand that whenever possible, the staff will make a good faith effort to contact me or the above-named person(s) before seeking treatment. If this is not possible, I understand that the staff will notify me or my designee as soon as possible of any and all diagnoses and treatments. *Legal Guardian s Signature Date Print Name Contact Phone Number Deadline to submit forms: May 1,

3 LIABILITY WAIVERS Please read the liability release waivers below and sign in all applicable places. Your Name (Please print) ADF# Age: AMERICAN DANCE FESTIVAL I warrant and represent to ADF that: (1) I am in good physical and mental health as of today's date; (2) I have no knowledge of any medical conditions of any kind that would affect my participation in the American Dance Festival in any way whatsoever; (3) I am fully familiar with the procedures required for my participation in the American Dance Festival; and (4) I acknowledge complete understanding of the risks involved in my participating and engaging in the American Dance Festival, including but not limited to, risks of property damage or loss of property, risks of physical injury and/or death. On behalf of myself and my executors, personal representatives, administrators, heirs, successors, and assigns (collectively, the Releasing Parties ), I hereby release, waive, and forever discharge ADF and its affiliates, subsidiaries, parent companies, related entities, and each of their respective shareholders, predecessors, successors, subsidiaries, assigns, owners, executors, administrators, agents, designees, officers, directors, employees, staff, trustees, members, heirs, successors, insurers and assigns (collectively, the Released Parties ) from any and all claims, actions, causes of action, liabilities, losses, demands, damages, costs, expenses, including reasonable attorneys fees or any compensation or relief whatsoever (hereinafter Claims ), which I or the Releasing Parties now have or may hereafter have arising out of and/or related in any way to my participation in the Activities, including, but not limited to, all claims for personal injury, wrongful death, workers compensation benefits, and claims arising from strict liability, whether caused by negligence or otherwise. I/we hereby acknowledge and expressly agree that this release is intended to be as broad and inclusive as permitted by law. If any one or more of the provisions of this waiver is held to be invalid, unenforceable, or against public policy, the validity, legality and enforceability of the remaining provisions will not in any way be affected or impaired thereby and shall remain in full force and effect. If any one or more of the provisions of this waiver is held to be excessively broad in any way, such provisions will be construed by limiting, reducing and/or altering them so as to be enforceable to the maximum extent compatible with applicable law. On behalf of myself and the Releasing Parties, I specifically waive any claim that this Release or any provision hereof is unenforceable and/or void against public policy that I or the Releasing Parties may be entitled to make or that may be made on behalf of my estate or by anyone who would sue because of my injury or death. I make these representations to the American Dance Festival with the full understanding that the American Dance Festival is relying on these representations. I agree that I will not hold liable the following for injuries sustained, death, or illnesses contracted by me while a student/participant at the American Dance Festival: the American Dance Festival, the studios where classes will be held, or any faculty member or employee of either. I agree to indemnify the American Dance Festival and its employees for all liabilities, costs, and judgments arising from acts or omissions of the undersigned which result in injury or damage to any person or party or from any and all Claims arising out of and/or related in any way to my participation in the activities hereunder or in connection with the American Dance Festival. I further agree that I will not hold the following responsible for the loss or damage of personal property during the American Dance Festival: the American Dance Festival, the studios where classes will be held, or any faculty member or employee of either. I agree to abide by the rules and regulations of the American Dance Festival and of the studios where classes will be held. I have read and understand the refund policies for the program for which I am applying and agree that I am only entitled to a refund under the terms and conditions specified. If you reside in the state of California: It is further understood and agreed that I expressly waive all rights under Section 1542 of the Civil Code of California. Said section reads as follows: A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor. Notwithstanding the provisions of Section 1542, and for the purpose of implementing a full and complete release and discharge of the American Dance Festival, I expressly acknowledges that this Agreement is intended to include in its effect, without limitation, all claims which I do not know or suspect to exist in my favor at the time of execution hereof, and that the settlement agreed upon contemplates the extinguishment of any such claim or claims. This Agreement shall be and remain in effect as a full and complete general release notwithstanding the discovery or existence of any additional or different facts. In consideration for my participation in the American Dance Festival, I acknowledge and agree that the American Dance Festival may produce certain media (including, without limitation, videotapes, audiotapes, photographs and other electronic media) for its archival, educational and marketing purposes which record the work and presence of the students (including, myself) at the American Dance Festival. I hereby grant the American Dance Festival the right and permission to use in any and all media now known or hereafter invented, throughout the world in perpetuity, my name, voice, image and likeness for archival, educational and marketing purposes, and I agree that I will not receive any compensation in return. DUKE UNIVERSITY I certify that the Participant, (name), will participate in the American Dance Festival and is insured under the insurance I included in this packet of forms and that the information is current and accurate. I have verified with my insurance company and/or agent that my health and accident insurance covers the Participant in Durham, North Carolina where the Program will occur and expires on. I hereby assume responsibility for all medical expenses the Participant incurs while he/she participates in any activity of the Program. I understand and agree to bear all financial responsibility for any medical treatment arising from the Participant s participation in the Program, and specifically to maintain throughout the Program coverage under a policy of comprehensive health and accident insurance. Such policy shall provide coverage for injuries and illnesses the Participant sustains or experiences while participating in the Program. I further agree and understand that Duke University shall not provide medical insurance for, or assume financial responsibility for, any injury or illness the Participant incurs while participating in the Program. I understand that I must make provisions before departure for the continuation of any medical treatments, the meeting of any special medical or nutritional needs, and the securing of any special services or facilities that the Participant may need during the Program. Duke University makes no representation with respect to the availability or quality of any medical services or medical facilities during the Participant s participation in any activity of the Program. I/We further agree that the Program reserves the right to make cancellations, changes, and substitutions in case of emergency or changed conditions, or if such are in the best interests of the group affected. Should the University cancel this Program, full refunds of the Program fees will be made unless the cancellation is due to causes outside of the control of the Program, in which case the Program will refund only uncommitted and recoverable funds. In addition, it is agreed that the cost of travel to and from the Program is not included in any fees that may be refunded. I/We further agree that in the event Participant is withdrawn from the Program due to a medical condition or injury, I agree to remove the Participant forthwith. I am solely responsible for paying the Participants non-scheduled transportation and any incidental travel expenses back to the Participants original point of departure. RELEASE AND WAIVER OF LIABILITY In return for Duke University permitting the Participant to register and participate in the Program, I/we hereby voluntarily agree to the following: A. I/WE RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Duke University, its affiliates, trustees, officers, employees or agents, (hereinafter referred to as RELEASEES) for any liability, claim, and/or cause of action arising out of or related to any loss, damage, injury or harm of any sort, including death, that may be sustained by the Participant, and for damage to any property belonging to him/her, that occurs as a result of traveling to or from any site in connection with the Program, or as a result of the Participant s participation in the Program. It is our intent and agreement that the terms of this Release and Waiver of Liability shall bind any person asserting rights on our behalf, or otherwise asserting claims by or through us, including my spouse, family members, heirs, assigns and personal representatives. Deadline to submit forms: May 1,

4 B. I/We further agree that this Release and Waiver of Liability shall be construed in accordance with the laws of the state of North Carolina. Further, the release, waiver, discharge and covenant not to sue as expressed in this section is given pursuant to the Uniform Contribution Among Tortfeasors Act, North Carolina General Statutes Section 1B et seq. It is my/our intention not only to release any and all claims against RELEASEES, but also to relieve RELEASEES from any liability to make contribution to other tortfeasors on account of any claims. C. In signing this Waiver and Release, I/We acknowledge and represent that I/we have informed ourselves fully of the contents of this Waiver and Release of liability and hold harmless agreement by reading it before we sign it, and that I/we have reviewed it and Participant understands what it means and that I/We sign this document freely. I/We further state that there are no health-related reasons or problems which preclude or restrict the Participant s participation in this Program. This Release constitutes the entire understanding of the parties hereto with respect to the subject matter of this Release, and supersedes any and all prior and oral and/or written representations, understandings and/or agreements relating to the subject matter hereof. This Release may not be altered or modified except in a writing signed by all parties hereto. This Release shall be binding upon and inure to the benefit of the each of the parties hereto and their respective successors and assigns. [NOTE: Participant and the Participant s Parent/Guardian agree that this Release and Waiver of Liability may be executed in counterparts (i.e., each required signature may appear on separate printed copies of the Release and Waiver of Liability), and that such counterpart versions each shall be deemed an original and together shall constitute one and the same document for legal purposes.] By signing below, you agree to all terms listed in both the American Dance Festival and Duke University sections above: Participant: Date: I am the parent or guardian of the above-named Participant. I have reviewed this Duke Medical Form and Release and Waiver of Liability and the description of the Program, have discussed it with the Participant and concur with the Participant s participation in the Program under the terms of this Release and Waiver of Liability. Signature of Parent/Guardian: Date: (if student is under age 18) Witness Signature Date (Witness signature required, but need not be notarized.) DUKE UNIVERSITY PARTICIPATION AGREEMENT FOR MINORS (ONLY PARENTS/GUARDIANS OF STUDENTS UNDER THE AGE OF 18 MUST READ AND SIGN THIS SECTION) The above named child, and the parent or legal guardian of the above named child, who is under 18 years, as a participant in the American Dance Festival activities, do hereby acknowledge, agree, promise and covenant with Duke University and its trustees, officers, employees, agents and all other persons or entities, and do hereby release, hold harmless and discharge Duke University and its trustees, officers, employees, agents and all others persons or entities involved with the American Dance Festival and Duke University from any and all liability for any injury, death, illness, disease and damage which my child might sustain while participating in activities sponsored by or associated with the American Dance Festival. I execute this release on behalf of and with specific intent to legally bind myself, my heirs, assigned personal representatives and estate. I hereby certify that my child has no medical conditions which will prevent normal participation in the subject event or program. I further understand and acknowledge that no medical insurance benefits will be provided for my child during this event. I hereby certify that my child will voluntarily participate in the American Dance Festival and I hereby grant permission to those appropriate personnel of the American Dance Festival programming staff to seek medical assistance for my child should the same be required, recognizing that no member of the American Dance Festival staff assumes responsibility for, nor do they have any liability for, the medical assistance and care which may be so selected and provided. PLEASE READ THIS AGREEMENT CAREFULLY. IT IS A LEGAL CONTRACT AND AFFECTS ANY RIGHTS YOU MAY HAVE IF YOU ARE INJURED OR OTHERWISE SUFFER DAMAGES WHILE PARTICIPATING IN THIS ACTIVITY. In consideration of Duke University allowing me to participate in this activity, I agree and understand the following: RELEASE, ASSUMPTION OF RISK, WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT In return for Duke University allowing me to participate in this activity and having read and understood this Participation Agreement, I hereby state that I voluntarily agree to the following: A. I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Duke University, its trustees, officers, employees or agents, (hereinafter referred to as RELEASEES) for any liability, claim, and/or cause of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me that occurs as a result of my traveling to and from, and participation in this activity. B. I agree to INDEMNIFY AND HOLD HARMLESS the RELEASEES whether injury or damages is caused by my negligence, the negligence of the RELEASEES or the negligence of any third party from any loss, liability, damage or costs, including court costs and attorneys' fees, that RELEASEES may incur due to my traveling to and from, and participation in this activity. C. It is my express intent that this RELEASE and HOLD HARMLESS AGREEMENT shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISHCARGE and COVENANT NOT TO SUE the above-named RELEASEES. D. I hereby further agree that this Participation Agreement, Release, Assumption of Risk, Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the state of North Carolina. Further, the release, waiver, discharge and covenant not to sue as expressed in this Section 4 is given pursuant to the Uniform Contribution Among Tortfeasors Act, North Carolina General Statutes Section 1B et seq. It is my intention not only to release any and all claims against RELEASEES, but also to relieve RELEASEES from any liability to make contribution to other tortfeasors on account of any claims. E. If I deviate from any aspect of this activity, such deviation is purely voluntary, and I agree that RELEASEES shall not be liable or any injuries resulting or arising out of such deviation. F. I understand that by participating in this activity I will ASSUME THE RISK of injury and damage from risks and dangers that are inherent in any activity. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT that I have read the foregoing PARTICIPATION AGREEMENT, understand it, and sign it voluntarily. This Release constitutes the entire understanding of the parties hereto with respect to the subject matter of this Release, and supersedes any and all prior and oral and/or written representations, understandings and/or agreements relating to the subject matter hereof. This Release may not be altered or modified except in a writing signed by all parties hereto. This Release shall be binding upon and inure to the benefit of the each of the parties hereto and their respective successors and assigns. Parent/Guardian Printed Name: Parent/Guardian Signature: Date: Deadline to submit forms: May 1,

5 Duke University Waiver of Liability and Assumption of Risk for Use of Duke University Recreation Facilities I understand that participation in all activities in the Wilson/Brodie Recreation Centers ( W/BRC ) are completely voluntary, and all participants are responsible for their own welfare. I agree to take personal responsibility for using proper footwear and clothing while in the recreation facilities. I understand that Duke University requires that each participant have personal medical coverage. While on Duke s premises, I will adhere to Duke s policies and regulations including but not limited to parking, traffic and security regulations and with all other ordinances, laws, and regulations that may be required by Federal, State, and Local Governments or Insurance and Health Agencies. I further assume responsibility and liability for all damage to Property caused by, resulting from, or arising out of my use of Duke facilities and Duke premises. All of my activities will be at my own risk, and I am hereby given notice of its responsibility to make arrangements to guard against physical, financial, and other risks as appropriate. I understand that Duke shall have no responsibility for the loss, theft, mysterious disappearance of, or damage to personal property which may be brought into W/BRC; except for damage caused by direct and sole negligence of Duke. I agree to indemnify and hold harmless Duke, including its trustees, officers, directors, employees and agents, from any claim, damage, liability, injury, expense, including reasonable attorney s fees, or loss arising directly or indirectly out of its use of Duke facilities and Duke premises. I certify that the information I have provided above is correct and I agree to abide by all rules and regulations governing the recreational facilities. I have read and understand all policies and procedures of W/BRC, and accept responsibility for abiding by all regulations and policies, which may from time to time be reasonably adopted. Signed Parent Signature (if under 18) Print name Date Deadline to submit forms: May 1,