SCI Overnight Adventure Participant Permission and Release REQUIRED: Complete separate form for each member of your group (adult and child) and mail to Jason Godfrey, 6123 Scout Trail, Des Moines, Iowa 50321.
ALL Participant Permission and Release forms should be at the Scout Office by November 14, 2013 Participant Name _________________________________________________
□ Adult
□ Youth (ages 6 - 14)
Address ________________________________________________________ Overnight Date: November 22, 2013 Parent/Guardian Name (if under 18) __________________________________ Cell Phone _______________________ *Please bring with you the night of the event. This document contains a release of claims, so please read it carefully before signing. By being allowed by the Science Center of Iowa to participate in the Overnight Adventure program: I have read the rules agree to accept and abide by the regulations of the program as established by SCI and to obey the direction of SCI representatives. I understand that photography and/or video production may be conducted during my stay and grant SCI full and irrevocable consent to reproduce, copyright, publish, display or otherwise use my likeness and/or voice. I understand that neither medical nor health insurance coverage is supplied by SCI and that each participant is responsible for all insurance coverage. I understand and expressly assume the risk of any and all damage, injury, death or harm which may occur to me or to my property during my stay at SCI. I forever release, discharge and hold harmless the Science Center of Iowa, its officers, directors, employees, agents, assigns and insurers from any and all claims or liability arising out of or in connection with participation in an Overnight Adventure. This release includes, but is not limited to, libel, invasion of privacy, negligence or other fault that result in personal injury, death, property damage or any type of damage or injury during or in connection with Overnight Adventures. This release will be construed according to the law of the state of Iowa. This permission and release shall endure to the benefit of licensees and assigns of SCI and shall be binding upon myself and/or my child, spouse and my/his/her/heirs, estate, personal representatives and assigns. I have read the “Successful Overnight Adventure” form. I acknowledge that I have received, read, understood and agreed to the above and I voluntarily sign this agreement.
______________________________________________ _____________________________________________ Participant Signature (if older than 18) Print Participant Name ______________________________________________ _____________________________________________ Parent/Guardian Signature (if younger than 18) Print Parent/Guardian Name
Contact us with questions at
[email protected] or (515) 274-6868 ext. 222. 400 W. Martin Luther King J r. Parkway, Des Moines, Iowa 50309
