Emergency Contact Information

Your consent is greatly appreciated as it allows photos taken during this program to be used by the Movement Education Outdoors in the future, but it is not required. Photos of our activities help our fundraising efforts. We’d greatly appreciate your consent!

I hereby authorize Movement Education Outdoors (including periodicals, other printed matter, or electronic media, and their editors) to use my photograph or reproduction in any medium the Movement Education Outdoors see fit for the purposes of education, advertising, display, exhibition, or editorial use.

PLEASE READ CAREFULLY!

Participants (or parents/guardians, if appropriate) must read and sign below. Participant acknowledgment of accuracy and understanding. By signing this form, I am declaring that, to the best of my knowledge, I have completed the questionnaire accurately. I also understand that by knowingly filling out the form inaccurately, or by withholding pertinent information about my health, I could potentially be increasing the risk to myself or others.

Consent to accept aid. By signing this form, I am giving consent and permission for Movement Education Outdoors staff, volunteers, representatives, or contractors to provide medical care to me or to my child, to transport me or my child to a medical facility, or to seek the aid of emergency medical services as deemed appropriate. I further authorize Movement Education Outdoors staff, volunteers, representatives, or contractors to render whatever treatment they consider necessary for me or my child’s health, and I agree to pay all costs associated with that care and transportation.

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INTRODUCTION

PLEASE READ THIS ENTIRE THREE-PAGE DOCUMENT (hereafter 'Document') CAREFULLY BEFORE SIGNING. All participants must sign this Document For participants under 18 yrs. of age (hereafter sometimes ‘minor’ or ‘child’), one or both parent/s or guardian/s (hereafter collectively ‘parent/s’) must also sign. In consideration of the services of Movement Education Outdoors Sole proprietorship, organized and existing under the laws of Rhode Island, and it’s independent contractors, volunteers (including leaders and co-leaders), members, and all other persons or entities associated with it, I (participant and parent/s of a minor participant), acknowledge and agree as follows Movement Education Outdoors uses volunteers to assist with, and sometimes lead activities, workshops or programs. These individuals are not paid professional guides or leaders. In all activities, all participants share in the responsibility for their own safety and the safety of the group.

ACKNOWLEDGMENT & ASSUMPTION OF RISKS Movement Education Outdoors instructional, educational and/or adventure activities (which may be scheduled or unscheduled, supervised or unsupervised and/or occur during free time) include, but are not limited to hiking, camping, skiing, snowshoeing, canoeing, high and low ropes courses, environmental education, participation in volunteer service projects and transportation or travel to and from activities (referred to in this Document as 'activities' or 'these activities'). These activities include inherent and other risks, hazards and dangers (referred to in this Document as ‘risks’) that can cause or lead to injury, damage, death or other loss to participant or others. The following includes some, but not all of those risks:

Risks present in an outdoor, mountainous or wilderness environment on land or water, both on and off trail. Travel can be subject to storms, strong winds, currents, waves, lightning, rapidly moving rivers or other water bodies, difficult stream crossings, snow or ice, extremely hot, humid or cold weather or water, steep terrain, falling rock, stinging or disease carrying animals or insects, wild animals and other natural or human-made hazards and dangers. Hazards may not be marked, and weather is unpredictable year-round. Risks in decision making, including, without limitation, the risk that Movement Education Outdoors may misjudge a participant’s capabilities, health or fitness level, or misjudge some aspect of instruction, medical treatment, weather, terrain, water level, or route location. Personal health and participation risks. The risk that a participant’s mental, physical or emotional condition (disclosed or undisclosed, known or unknown) combined with participation in these activities could result in injury, damage, death or other loss. The risk that equipment used in an activity may be misused, or may break, fail or malfunction.

Movement Education Outdoors activities may take place in remote places, several hours or days from any medical facility, causing potential delays or difficulties with communication, transportation, evacuation and medical care. Risks connected with meals and/or cooking and camping chores. Meals may include exposure to food allergens. Risks also include gas explosion, scalding or other burns associated with cooking over a gas stove or open fire, and water contamination from natural water sources. All water may be contaminated and should be disinfected, filtered or boiled before use. Risks associated with transportation. Travel can be on foot or by vehicle, boat or other means and can be over rough and unpredictable terrain or via rivers, with wind, rain, or other adverse weather conditions. Participants may have limited, unsupervised time during, before or after the start of Movement Education Outdoors program. This may include periods of free time, or periods of time alone while engaged in backcountry travel. During both supervised and unsupervised activities, all participants share in the responsibility for their own safety and the safety of the group. Other risks that are generally associated with instructional, educational and/or adventure activities. These and other risks may result in participants falling, being struck, colliding with objects or people, experiencing vehicle or boat collision or capsize, drowning, reacting to weather conditions or increased exertion, suffering gastro-intestinal complications or allergic reactions, becoming lost or disoriented, or experiencing other problems. These and other circumstances may cause hyperthermia, hypothermia, frostbite, dehydration, burns, heart or lung complications, broken bones, concussions, paralysis, mental or emotional trauma, or other injury, damage, death or loss.

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I (participant and parent/s of a minor participant) agree:

• To accurately complete all required forms (which may include, but is not limited to the Movement Education Outdoors application, registration and medical forms), abide by the terms of those documents, and obey all Movement Education Outdoors, regulations and policies;

• If participant has any mental, physical or emotional conditions or limitations that might affect his/her ability to participate I agree to disclose those to Movement Education Outdoors, and represent that participant is fully capable of participating without causing harm to him/herself or others;

• Movement Education Outdoors is, and has been available, should I have further questions about these activities and the associated risks;

• Movement Education Outdoors cannot assure participant's safety or eliminate any of these risks.

Participant is voluntarily participating with knowledge of the risks. Therefore, participant (and parent/s of minors) assume and accept full responsibility for the inherent and other risks (both known and unknown) of these activities, and for any injury, damage, death or other loss suffered by participant (and parent/s of minors), resulting from those risks and/or resulting from participant’s negligence or other misconduct.

RELEASE AND INDEMNITY AGREEMENT

Please read carefully. This Release and Indemnity agreement contains a surrender of certain legal rights. I (adult participant, or parent/s for themselves and for and on behalf of their participating minor child) agree as follows:

(1) to release and agree not to sue Movement Education Outdoors, with respect to any and all claims, liabilities, suits or expenses (including attorneys’ fees and costs) (hereafter collectively ‘claim’ or ‘claim/s’) for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or participation in these activities, or use of Movement Education Outdoors equipment, facilities or premises. I understand I agree here to waive all claim/s I or my child may have against Movement Education Outdoors, and agree that neither I, my child, or anyone acting on my or my child’s behalf, will make a claim against Movement Education Outdoors, as a result of any injury, damage, death or other loss suffered by me or my child;

(2) to defend and indemnify (‘indemnify’ meaning protect by reimbursement or payment) Movement Education Outdoors with respect to any and all claim/s brought by or on behalf of me, my child or a family member for any injury, damage, death or other loss in any way connected with my/my child's enrollment or participation in these activities or use of Movement Education Outdoors equipment, facilities or premises.

This Release and Indemnity Agreement includes claim/s resulting from Movement Education Outdoors negligence (but not its gross negligence or intentional or reckless misconduct), and includes claim/s for personal injury or wrongful death (including claim/s related to emergency or medical response, assessment or treatment), property damage, breach of contract or any other claim.

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CONCLUSION

I(participant and parent/s of a minor participant) agree that the substantive laws of Rhode Island govern this Document, any dispute I have with Movement Education Outdoors and all other aspects of my relationship with Movement Education Outdoors, and that any mediation, suit, or other proceeding must be filed or entered into only in Rhode Island.

Movement Education Outdoors reserves the right to remove any participant from the program who staff or leaders believe, in their discretion, presents a safety concern or medical risk, is disruptive, or acts in any manner detrimental to the program. If participant is dismissed or departs for any reason, participant (and his/her family) are responsible for all costs of early departure whether for medical reasons, dismissal, personal emergencies or otherwise. These costs include, but are not limited to medical evacuation and costs, plane, train or taxi fare, accommodations, and costs and compensation for staff accompanying participant.

This Document is intended to be interpreted and enforced to the fullest extent allowed by law. Any portion of this Document deemed unlawful or unenforceable shall not affect the remaining provisions, and those remaining provisions shall continue in full force and effect.

Participant and parent/s of a minor participant agree:

I have carefully read, understand and voluntarily sign this -page Document and acknowledge that it shall be effective and binding upon me, my minor children and other family members, and my heirs, executors, representatives and estate. One or both parent/s must sign below for any participating minor (those under 18 years of age).