email newsletter services. I understand my info will not be shared with or sold to anyone. PLEASE INITIAL THE FOLLOWING:
Sleep with the Sharks Release Waiver Please use a separate form for each participant.
Participant’s name:
DOB:
Gender: M
F
Parent/Guardian Name (minors only): Mailing address: Evening phone:
Cell phone:
Email: q Please include me in the Aquarium’s free email newsletter services. I understand my info will not be shared with or sold to anyone. PLEASE INITIAL THE FOLLOWING: I hereby release the Oregon Coast Aquarium officers and its employees from any claims which I might have for injuries or damage resulting from failure to obey and cooperate as instructed or as a result of the risks and dangers involved in this activity. In the event that my I / the child needs medical treatment, I hereby consent and authorize the accompanying representative of the Oregon Coast Aquarium to permit treatment. I agree to be responsible for the cost of any medical services and to indemnify the Oregon Coast Aquarium for such expenses. I hereby authorize Oregon Coast Aquarium personnel to photograph / video myself / the child for the purposes of education and promotion of Aquarium programs. I understand that these images may be used in a variety of ways, including videos, publications and websites. (By not initialling, you REVOKE consent.) I / the child do not have any physical or mental conditions which would restrict or prevent me / the child from participating in any scheduled activity, or which would increase the risk of harm with the exceptions listed on the medical form. Non-Discrimination Policy: The Oregon Coast Aquarium is proud of our diverse and inclusive programs. Consistent with our corporate non-discrimation policy and applicable laws, OCAq programs are open to everyone regardless of race, color, gender, national origin, age, religion, creed, disability, veteran’s status, sexual orientation, gender identity or gender expression. Continued on back
2820 SE Ferry Slip Road, Newport, Oregon 97365 (541) 867-3474 | www.aquarium.org
Sleep with the Sharks Personal & Medical Information Please use a separate form for each participant. This form is confidential.
Participant’s name:
DOB:
Gender: M
F
Parent/Guardian Name (for minors only): MEDICAL INFORMATION In case of emergency, please list the name and phone number of a second party who could respond. Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Does this person have any allergies, medical / behavioral issues, special needs etc. which our staff should be aware of or which may require special accommodations?
MEDICAL POLICY: In the case of medical emergency, it is Oregon Coast Aquarium policy to contact 911 immediately. Parents / guardians will be contacted after emergency services have been activated. Oregon Coast Aquarium staff are certified in CPR and Basic First Aid, but will not treat any serious medical condition nor administer medications of any kind. All information released by an individual/parent/guardian on this form is considered confidential and will not be released to any third party. Signature: (Parents must sign for minors.) Printed Name: Date:
2820 SE Ferry Slip Road, Newport, Oregon 97365 (541) 867-3474 | www.aquarium.org
Personal Release and Information for Students and Participants in Oregon Coast STEM Hub Activities 2016-2017 School Year Medical Release As custodial parent or legal guardian, I hereby give consent and permission for the child named below to participate in ACTIVITY program sponsored, conducted and presented by Oregon Sea Grant at Oregon State University Hatfield Marine Science Center. On behalf of myself and my child, I hereby release and discharge Oregon Sea Grant and Oregon State University Hatfield Marine Science Center, its officers, directors, agents, volunteers and employees from any claims which I or other representatives of this child might have for injuries and damage resulting from failure to obey and cooperate as instructed, and as a result of the risks and dangers involved in this activity. In the event this child needs medical treatment, I hereby consent and authorize a representative of Oregon Sea Grant or Oregon State University Hatfield Marine Science Center to permit treatment on my behalf, and to sign any documents requested by any physician or medical facility to provide treatment. I agree to be responsible for the cost of any medical services and to indemnify the Oregon State University Hatfield Marine Science Center, for such expense. I further declare that the child named does not have any physical or mental conditions which would restrict or prevent him/her from participating in the scheduled activities.
Student Name (PRINT) : ____________________________________________ Parent/Guardian Name (PRINT): ______________________________________ Parent Guardian Signature: __________________________________________
Date: ____________________
Video/Photo Waiver I authorize the Oregon Coast STEM Hub and its partners, including Lincoln County School District, Oregon State University, Oregon Sea Grant, Hatfield Marine Science Center, and Oregon Coast Aquarium, acting pursuant to their authority to:
(a) Record me on videotape or audiotape, in photographs, or in any other recorded medium. I understand that these recordings may be used in any medium, including print, World Wide Web, video, or audio. (b) Over 18: Use my name, likeness, voice, and biographical material in connection with recordings. Under 18: Use my likeness and voice only. No names will be associated with likenesses. (c) Exhibit or distribute such recording in whole or part without restrictions or limitation for any educational or promotional purpose, which the Oregon Coast STEM Hub partners cited above and those pursuant to their authority deem appropriate. I waive any right to inspect or approve the finished medium or the use to which it may be applied. I represent that I have read and fully understood the above paragraphs and am knowingly and voluntarily executing this release. Participant Name (PRINT) : ____________________________________________ Parent/Guardian Name (PRINT): ______________________________________ Parent/Guardian Signature: __________________________________________ Address: _________________________________________________________ Phone: ________________________ Email: ____________________________
Date: ____________________
Optional Information
Ethnicity ___ African America ___ Asian ___ Hispanic ___Native American ___Pacific Islander ___White Gender __Male __Female Age___ Grade___
School District ___Astoria ___Knappa ___Warrenton-Hammond ___Seaside ___Jewell ___Neah-Kah-Nie ___Tillamook ___Lincoln County ___Siuslaw ___Mapleton ___Reedsport ___North Bend ___Coos Bay ___Coquillle ___Myrtle Point ___Powers ___Bandon ___Centralo Curry ___Port Orford /Langlois ___Brookings-Harbor ___Other: _______________________
