Tommy Trojan

323-123-4567

Parkside, Encounter, New to Faith, etc.

You will be reimbursed for gas.

Don't forget to include yourself!

You will not be reimbursed for gas if you are driving.

(e.g. Father, Sister, etc.)

(sometimes this is called the policy number)

(e.g. food, medications, dietary restrictions, etc.)

1. In consideration for being accepted and allowed to participate in this conference/project and activities associated with its program and location, I personally assume responsibility for my actions, and release InterVarsity Christian Fellowship/USA® (hereafter InterVarsity®), its Trustees, employees and agents from loss, injury or damage to myself or my property; provided that nothing contained herein shall excuse InterVarsity, its Trustees, employees or agents from responsibility to act with reasonable care for the safety of myself or my property. 2. I give permission to InterVarsity to be photographed, recorded, and/or video taped and to allow this material to be used for publicity. 3. I give permission to InterVarsity to obtain medical assistance in the event of an emergency. This permission will include the administration of medicines, surgical treatment, X-ray examination or hospitalization as might be ordered by a licensed medical doctor. I release and discharge InterVarsity, its trustees, employees, and agents from any liability for any first aid rendered or treatment performed pursuant to this consent. 4. I understand that InterVarsity has a hostage policy that states that InterVarsity should not yield to demands, including the payment of ransom or other extortion, issued through the use of hostage taking or extortion. 5. If I am under age 18, I state that I am a mature minor (of college age and living away from parent/guardian) and have the capacity to consent to the terms of this Release. 6. Any claim or dispute arising from or related to this release shall be settled by mediation and, if necessary, legally binding arbitration in accordance with the rules of a mutually agreed upon alternative dispute resolution service, subject to provisions of federal, State and local law governing arbitration, including, but not limited to jurisdiction and allocation and payment of costs. Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. These methods shall be the sole remedy for any controversy or claim arising out of this agreement and the parties expressly waive any right to file a lawsuit in any civil court for such disputes, except to enforce an arbitration decision. I certify that I am competent to sign this Release, and have done so voluntarily.