Environmental Learning Institute TORCH 2007
Informed Consent Form
Phone: (520-245-3711) E-mail: firstname.lastname@example.org
Please FAX this form to: 480-275-3318.
Participant's Full Name:
Social Security #:
Name of Person To Be Notified in Case of Emergency:
Medical Health Insurance Carrier Name:
Understanding & Assumption of Risk
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.
Authorization for Medical Care
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: