Lagoon Castaway Camp Application

Lagoon Castaway Camp Application

Student Information
Name:*
Age*
Address:*
Phone:
-
E-mail:
Allergies or Special Notes:
Parent/Guardian Information
Parent/Guardian Name:*
Parent/Guardian Address:*
Parent/Guardian Phone:*
-
Alternate Phone:*
-
Parent/Guardian E-mail:*
Is Emergency Contact information the same as the Parent/Guardian information shown above?
Emergency Information
Emergency Contact's Name:*
Emergency Contact's Address:*
Emergency Contact's Phone:*
-
Emergency Contact's Alternate Phone:*
-
Emergency Contact's E-mail:*

Waiver, Release And Hold Harmless Agreement

In consideration of permission granted by the Marine Resources Council of East Florida (MRC) allowing me to participate in any of their programs, I (together with my parent or guardian, if I am under the age of (18) or under legal disability) represent, covenant and agree, on behalf of myself and my heirs, assigns, and any other person claiming by, under or through me, as follows:

1. I acknowledge that participating in any of these programs involves certain risks (some of which I may not fully appreciate) and that illness, disease, infection, injuries, including permanent disability, paralysis and death, property damage or other harm could occur to me and others by my own actions or inactions. I accept and voluntarily incur all risks of any illness, disease, infection, injuries, damages, or harm which arise during or result from my participation in the program, including any associated travel, regardless of whether or not caused in whole or in part by negligence or other fault of MRC, and/or its board members, affiliates, employees, volunteers, insurers, partners, or interns (“Released Parties”).

2. I waive all claims against any of the Released Parties for any injuries, damages, losses or claims, whether known and unknown, which arise during or result from my participation in the program, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties. I release and forever discharge the Released Parties from all such claims.

3. I agree to indemnify and hold harmless the Released Parties harmless from all losses, liabilities, damages, costs or expenses (including but not limited to reasonable attorney’s fees and other litigation costs and expenses) incurred by any of the Released Parties as a result of claims or suits that I (or anyone else claiming by under or through me) may bring against any of the Released Parties to recover losses, liabilities, costs, damages, or expense which arise during or result from my participation in the program, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties.

4. I have carefully read and reviewed this Waiver, Release and Hold Harmless Agreement. I understand fully and execute it voluntarily.

Consent To Use Name, Photograph, Film, Audio, Or Videotape For Non-Profit Use (e.g. educational, public service, or awareness purposes)

I hereby consent to the use of the organizational and individual name listed above, the use of audio, the use of quotes, and the taking of photographs, movies or video tapes of the individual named above by the Marine Resources Council. I also grant to the Marine Resources Council the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I hereby release the Marine Resources Council and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Student Acknowledgment:*
Student Name:*
Parent or Guardian Acknowledgment:*
Parent or Guardian Name:*
Date:*

Note: After submitting your application, you will be redirected to our EventBrite page to complete payment for this program.

Verification:
Marine Resources Council • 3275 Dixie Hwy, NE, Palm Bay, FL 32905 ©2013 All Rights Reserved
This page is managed by the Marine Resources Council, a 501(c)(3) nonprofit organization that has been dedicated to protecting and restoring the Indian River Lagoon for nearly 30 years.