Feast of Freedom (California) Survivor Scholarship Registration

Name

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Phone

Mailing Address

Why do you want to attend the conference?

I, the undersigned, do hereby release, forever discharge and agree to hold harmless Emerald of the Sea, it's members, directors,employees, and volunteers from any and all liabilty, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned participant while involved in the activities. My electronic signature will act as the acceptance of this liability release.

I acknowledge that I have voluntarily agreed to participate in Emerald of the Sea’s Conference and I enter into this agreement of my own free will. I understand fully the sensitive and graphic nature of the topics being discussed and furthermore understand it could trigger memories of past trauma potentially evoking an emotional, physiological, and/or physical response. I acknowledge that it is my responsibility to ascertain my own need for professional counseling or therapy and to seek such professional services as needed. I accept complete responsibility for my own psychological, mental, emotional, social, and spiritual well-being. I release Emerald of the Sea of any and all liability and hereby waive any and all rights, claims, or causes of action of any kind arising out of my participation in their conference. My electronic signature will act as the acceptance of this release form.

I authorize and consent for Emerald of the Sea to seek medical attention on my behalf in the event of an emergency. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to aforementioned participant pursuant to this authorization. My electronic signature will act as the acceptance of this medical release.

Emerald of the Sea and its affilitates has my permission to use any photographs and videos taken at the conference to publically promote the organization. I understand that the images may be used in print publications, online publications, presentions, websites and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. My electronic signature will act as the acceptance of this photo/video release form.

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Feast of Freedom (California) Survivor Scholarship Registration

Description

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