2023 Terms/Conditions • Emerge

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 6/23/2023 *

Attendee's Adult Unisex T-shirt Size *

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 2023 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 23, 2023 from 9:00 a.m. to 3:00 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, 2023 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.

E-Signature of Parent/Guardian completing Emerge 2023 Registration Form *

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