Environmental Learning Institute TORCH 2007
Informed Consent Form

Phone: (520-245-3711) E-mail: silverberg@alum.mit.edu
Website: www.environmentallearning.org

Please FAX this form to: 480-275-3318.

Participant's Full Name:

Course Title:
Course Date:

Zip Code:
Telephone #:

Social Security #:
Date of Birth:

Name of Person To Be Notified in Case of Emergency:
Relationship to Participant:
Phone #:

Medical Health Insurance Carrier Name:
Policy #:
Physicians Name:
Phone #:

Background Information
The Environmental Learning Institute (ELI) courses provide an action-oriented and experience-based approach to rigorous academic learning in the environmental sciences and science education. Participants may be asked to become engaged in a series of mentally and physically challenging activities such as backpacking, hiking, camping, rafting, snorkeling, field research. During and following the activities, discussions or debriefings focus on academic learning and professional development as well as seeing and understanding problem solving skills and areas of competence.

Understanding & Assumption of Risk
Due to the inherent nature of backpacking, hiking, camping, snorkeling, rafting and field research, you may be asked to take emotional, physical and mental risks. The physical and emotional safety of participants is always of the utmost and primary concern of the Staff. Individuals are always given a choice as to their participation.

I understand that I will be transported by the ELI TORCH staff, to and from the course site, and that such activity involves the risks inherent in vehicle travel.

I recognize and acknowledge that by participating in ELI TORCH courses there are certain physical and emotional risks. I understand that every care and attention will be given to the health and safety of the participants. I agree to assume and accept the full risk of any injuries, illness, damages, or loss which I may sustain as a result of my participation in any and all activities connected with or associated with ELI courses.

I understand that I should be free of any physical, medical, and/or mental conditions that may create undue risk to myself or others who may depend on me. If in doubt, I will seek medical advice before my participation in ELI TORCH courses. I also agree to inform the faculty of any situation(s) that may be a danger to my co-participants or myself. These situations may include: a) broken equipment, b) feeling sick or very tired, and c) having difficulty performing a skill. As a participant in ELI TORCH courses, I also agree to abide by any established rules and regulations set forth by the staff and understand that failure to comply with these rules may result in my removal from the course with no refund.

Waiver of Legal Claims
I understand and assume all risks associated with ELI TORCH courses. I understand that every care and attention will be given to the health and comfort of the participants, but the ELI and their staff cannot be held liable for any injuries, illness, or accidents due to my participation in this program. I waive and forever discharge all claims arising out of this program, whether caused by negligence, breach of contract or otherwise, for bodily injury, property damage or loss against ELI, their employees, administrators, directors, successors, assigns and their heirs.

Authorization for Medical Care
I have completed the Medical Form with health information that is accurate, complete, and true to the best of my knowledge. Should I become ill or injured, I give permission to the ELI staff to render first aid and to seek emergency medical and rescue service for myself. I acknowledge that I have medical insurance with coverage in the USA, Canada and Mexico during the time period of this course and that any medical and accident insurance I consider necessary will be my responsibility to locate and purchase.

Participant Signature

I have read and understand the Background Information, Understanding & Assumption of Risk, Waiver of Legal Claims, and Authorization for Medical Care. I understand the nature and risks of the course activities. I am voluntarily choosing to participate in the course activities. I have carefully read this agreement and understand its contents, and I sign it of my own free will. I am aware that this agreement includes a release of liability, and is a binding contract between the Environmental Learning Institute and me, and it likewise shall be binding on my heirs, executors, administrators and assignees.

Signature of Participant: