Registration Form • Emerge

PLEASE NOTE THIS IS A TWO STEP PROCESS. REGISTRATION IS NOT CONSIDERED COMPLETE UNTIL BOTH PARTICIPANT INFORMATION WITH CONSENTS (STEP 1) AND PAYMENT (STEP 2) IS COMPLETE. ONCE YOU HAVE SUBMITTED STEP 1, YOU WILL BE DIRECTED TO A LINK WITH STEP 2. YOU WILL ALSO RECEIVE ADDITIONAL INFORMATION VIA EMAIL ~1 MONTH AND ~2 WEEKS PRIOR TO EVENT.

Attendee's Name *

First

Last

Attendee's Email Address

Attendee's Mobile #

We use student mobile numbers for texting school visit information, updates, and/or emergencies

Attendee's Current School *

Attendee's High School Graduation Year *

Attendee's Age on 6/19/26 *

Attendee's Adult Unisex T-shirt Size - currently in design phase, alternative swag may be substituted *

Please choose sizes carefully. We want our Attendees to love their shirts!

Student is mature enough to be around and interact with medical equipment including needles and other sharp objects. *

Parent/Guardian Full Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Mobile # *

Street Address *

City *

State *

Zip Code *

Emergency Contact Name *

Please list someone else other than Parent/Guardian.

Emergency Contact Mobile # *

Dietary Restrictions

Students will be served a catered lunch

Please list any medical conditions/medications our staff should know about.

Please read and agree to our Refund Policy by checking the box *

I have read and agree.

REFUND POLICY: All Emerge 2026 Registration Payments are non-refundable. There are no exceptions, credits, transfers, and/or refunds. PLEASE DO NOT REGISTER UNTIL YOU ARE CERTAIN YOUR ATTENDEE IS AVAILABLE FRIDAY, JUNE 19th 2026 from 9:00 a.m. to 4:00 p.m.

Please read and agree to our Event Cancellation Disclaimer by checking the box *

I have read and agree.

EVENT CANCELLATION DISCLAIMER: Emerge Conference LLC is not responsible for problems beyond our control such as weather conditions, campus conditions, travel difficulties, health issues, etc). In the unlikely occurrence that our event has to be cancelled or postponed due to circumstances beyond the control of Emerge Conference LLC, we will not be held responsible for any costs incurred by event attendees and their parents/guardians.

Please read and agree to our Injury/Loss Disclaimer by checking the box *

I have read and agree.

INJURY/LOSS DISCLAIMER: Emerge Conference LLC does not accept responsibility and expressly excludes liability to the fullest extent permitted by law for: (1) any loss or damage to any personal property or (2) death or any personal injury suffered by attendees at the event. Authentic medical equipment will be used by attendees and proper use and care for these items is required. Emerge Conference LLC reserves the right to remove any attendee whose behavior is dangerous, disruptive, reckless, and/or not conducive to a learning environment.

Please read and agree to our Medical Release by checking the box *

I have read and agree.

MEDICAL RELEASE: As the Parent/Guardian (“undersigned”) of the above- named Attendee (“Minor”), the undersigned are responsible for the health care decisions of the Minor and is/are authorized to give consent for medical treatment to be provided to the Minor. The undersigned represents that no other consent from any other person(s) is/are required by law. The Undersigned do hereby authorize Emerge Conference LLC (EC-LLC) as agents for the Undersigned, to consent to any x-ray examination, anesthesia, medical or surgical diagnosis or treatment and hospital care of the Minor, which is deemed advisable by and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the provisions of the California Medical Practice Act (Business & Professions Code Sections 2000-2029) and on the medical staff of a licensed hospital/medical center, whether such diagnosis or treatment is rendered at the office of said physician or said hospital/medical center. It is understood and agreed that this authorization is given in advance of specific diagnosis, treatment or hospital care being required and is give to provide EC-LLC with the authority and power to give specific consent to any and all such diagnosis or treatment deemed advisable for the Minor. This authorization is given pursuant to Sections 6910/6911/6550 of the California Family Code and shall remained effective until December 31, 2026 unless revoked sooner in writing delivered to, and received by EC-LLC. It is also understood and agreed that the Undersigned is/are responsible for all costs relating to the necessary medical treatment, whether through insurance or other means, and that EC-LLC does not provide medical insurance coverage and is not responsible for any costs relating to medical treatment of the Minor. In addition to the above, the Undersigned agree(s) to allow the Minor to be photographed and/or videotaped for official publication purposes relating to EC-LLC (flyers, brochures, website, news media, etc).

Please read and agree to our Liability Release by checking the box *

I have read and agree.

LIABILITY RELEASE: The above-named Parent/Guardian hereby release(s), waive(s), and discharge(s) EC-LLC, its officers, agents, employees and representatives (hereinafter “Releasees”) from any and all liability, responsibility, damages, losses, and claims resulting from personal injury, accidents, and/or property loss caused in any manner, including the simple, active or passive negligence of Releasees, arising from or related to Minor’s participation in EC-LLC activities. The above-named Parent/Guardian further understand(s) and expressly agree(s) that the foregoing Medical Release Agreement and Liability Release Agreement (“Release Agreement”) is intended to be as broad and inclusive as is permitted by the laws of the State of California, including without limitation California Probated Code section 3500, et seq., and that if any portion of the Release Agreement is found invalid, it is agreed that the remaining provisions shall, notwithstanding, continue in full legal force and effect. By checking the box below, the above-named Parent/Guardian has carefully read this Release Agreement and fully understands its contents. They are aware that this is a release of liability and a consent to medical services, and further understand that the Undersigned is/are giving up substantial legal rights. The Undersigned is/are not relying on any representation by EC-LLC which is not set forth herein, and further understand(s) that any modification to this Release Agreement must be made by EC-LLC in writing. Parent/Guardian agrees to sign for the Minor listed on this Registration Form, and will update this form if information changes.

Photo Consent

I have read and agree

I hereby consent to and authorize Sharp HealthCare, or anyone authorized by Sharp HealthCare (e.g., news media or other external companies), to conduct interviews, take photographs, audio/visual recordings or to facilitate media requests for same, of my image, my voice, and related images, conversations and sounds, etc. (the “Recordings”), taken on June 19th, 2026. I hereby willingly grant, without compensation, to Sharp HealthCare and its assigns, the irrevocable and unrestricted right, but not the obligation, to use and publish the Recordings in any way it desires, including for news and feature stories, advertising and any other purpose and in any manner and medium (i.e., print, broadcast, online and all digital media, etc.), including the right to alter the same without restriction. I hereby release Sharp HealthCare and its assigns from all claims and liability relating to said Recordings. I hereby agree that all Recordings and all related biographical materials that I have provided are owned by Sharp HealthCare. I hereby waive any right of inspection or approval regarding my appearance in the Recordings or the uses to which they may be put. Sharp HealthCare may edit and/or include the Recordings or any portion thereof in such uses as are permitted above, at its sole discretion. I understand that Sharp HealthCare may, in its sole discretion, elect not to use my image. There is no time-limit on the validity of this release nor is there any geographic specifi cation of where these materials may be distributed. I have been given a copy of this release form for my records. I hereby acknowledge that I am 18 years of age or older and have read and understand the terms of this release and willingly sign this release on my own behalf or on behalf of the minor named above

Sharp Consent

I have read and agree

Location: Brown Simulation Center, 8695 Spectrum Center Blvd, San Diego, CA 92123. June 19th, 2026 9a-4p I the undersigned adult wishes to participate or I/We the undersigned wish for my/our Child (hereinafter “Child”) to participate in the above referenced program (hereinafter “Program”) on the date(s) and location(s) indicated above and, in consideration for my own and/or my/our Child’s participation, I/we hereby agree as follows: I/ We acknowledge, understand, and accept that the Program may be dangerous and may involve the risk that I and/or my/our Child will sustain serious injury, temporary or permanent disability, death, and/or economic and property damage. I/ We further realize that participating in the Program may involve risks and dangers, both known and unknown, including but not limited to my and/or my/our Child’s handling of needles and use of the defibrillator, and have elected to allow myself and/or my/our Child to take part in the Program. I AND/OR WE VOLUNTARILY AND FREELY ASSUME ALL RISKS AND DANGERS THAT MAY OCCUR PURSUANT TO MY AND/OR MY/OUR CHILD’S PARTICIPATION IN PROGRAM INCLUDING THE RISK OF INJURY, DEATH, OR PROPERTY DAMAGE. I/ We, on behalf of myself and/or my/our Child, hereby agree, on behalf of myself, my heirs and my personal representatives, to fully and forever discharge and release the Caster Nursing Institute and Brown Simulation Center (“Brown Simulation Center”), the Sharp Prebys Innovation & Education Center, Sharp HealthCare and/or its affiliates, and its and their respective directors, officers, employees, agents, representatives, successors and permitted assigns (“Released Parties”) from any and all claims I may have or hereinafter have for any injury, temporary or permanent disability, death, damages, liabilities, expenses and/or causes of action, now known or herein known in any jurisdiction in the world, attributable or relating in any manner to my and/or my/our Child’s participation in Program, whether caused by the negligence of Released Parties or by any other reason. I acknowledge and agree that this Release and Waiver of Liability is intended to be, and is, a complete release of any responsibility of the Released Parties for any and all personal injuries, temporary or permanent disability, death, and/or property damage sustained to me and/or my/our Child during Program. I and/or we agree, for myself and/or ourself, and all of my and/or our heirs, not to sue the Released Parties or initiated or assist in the prosecution of any claim for damages or cause of action against Released Parties which I and/or we and/or my heirs and/or our heirs may have as a result of any personal injury, death, or property damage I and/our my/our Child may sustain while participating in Program. I/ We, on behalf of myself and/or my/our Child, hereby agree to defend, indemnify and hold harmless the Released Parties from and against any third party losses, damages, actions, suits, claims, judgments, settlements, awards, interest, penalties, expenses (including reasonable attorneys’ fees) and costs of any kind specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim. for any personal injury, loss of life or damage to property, arising out of my and/or my/our Child’s participation in Program. I acknowledge and agree that I am and/or my/our Child is fully and solely responsible for any of my property and personally belonging and/or my/our Child’s personal belongings. I/we hereby certify that I and/or my/our Child have/has no known medical problems or conditions that would prevent me and/or my/our Child from participating in the Program. In the event of an accident or serious illness, I/we hereby authorize Sharp HealthCare and/or its affiliates to obtain medical treatment for me and/or my/our Child on my and/or our behalf. I/ we hereby hold harmless and agree to indemnify Sharp and Released Parties from any claims, causes of action, damages, and/or liabilities, arising out of or resulting from said medical treatment. I/we acknowledge that Sharp does not provide health and accident coverage to Program participants and that I and/or my/our Child have/has adequate health insurance necessary to provide for and pay any medical costs that may be attendant as a result of injury to me and/or my/our Child. I/ We further agree to accept full responsibility for any and all expenses, including medical expenses, that VOLUNTARY WAIVER, RELEASE OF LIABILITY & ASSUMPTION OF RISKS AGREEMENT may derive from any injuries to me and/or my/our Child that may occur during my and/or his/her participation in the Program. This Release and Waiver of Liability agreement (“Agreement”) will be governed by and interpreted in accordance with the laws of the State of California, without giving effect to the principles of conflicts of law of such state. I agree that any action arising out of this Agreement must be brought exclusively in any state or federal court located in California, in the county of San Diego. This Agreement contains the entire agreement between the parties to this agreement and the terms of this Agreement are contractual and not a mere recital. The information I/we have provided is disclosed accurately and truthfully. I/ we have been given ample opportunity to read this Agreement and I/we understand and agree to all of its terms and conditions. I/ we understand that I am and/or we are giving up substantial rights (including my/our right to sue) and acknowledge that I am and/or we are signing this Agreement freely and voluntarily and intend by my and/or our signature(s) to provide a complete and unconditional release of all liability to the greatest extent allowed by law. My and/or our signature(s) on this Agreement is/are intended to bind not only myself/ourselves and my/our Child but also the successors, heirs, representatives, administrators, and assigns of myself/ourselves and/or my/our Child. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ AND UNDERSTAND EACH OF THE ABOVE PROVISIONS. I ACKNOWLEDGE THAT PRIOR TO SIGNING THIS AGREEMENT I HAD THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY TO REVIEW THIS AGREEMENT. I AM AT LEAST EIGHTEEN (18) YEARS OF AGE AND FULLY COMPETENT, AND I EXECUTE THIS AGREEMENT VOLUNTARILY AND FOR ADEQUATE CONSIDERATION INTENDING TO BE FULLY BOUND

E-Signature of Parent/Guardian completing Emerge 2026 Registration Form *

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