ADULT LIABILITY FORM

ACE Adult Liability Form

Participant's Name *

Email *

Phone *

Date of Birth *

Address *

Address

City

State/Province

Zip/Postal

Emergency Contact Name *

Emergency Contact Phone *

Event/Trip Name *

Event/Trip Dates *

It is extremely important that you provide ANY pertinent medical history or information about existing conditions that may affect Participant:

Medications *

Allergies *

Other Medical Information *

Medical Insurance *

Insurance Contract/Policy # *

Check to Agree: *

I desire to participate in the event/trip named above (hereinafter collectively referred to as the “Activities”) operated or sponsored by American-Caribbean Experience (“ACE”). I understand and acknowledge that ACE will not allow me to participate in the Activities without releasing and holding ACE harmless from any liability arising out of participation in the Activities. (This also includes outside contracted activities such as snorkeling, fishing, etc.) I have investigated the risks involved in the Activities and fully understand and assume such risks. Specifically, I understand and acknowledge that I may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, loss or theft of personal property, imprisonment, abduction and even death.

Check to Agree: *

I request that ACE allow me to participate in the Activities, and in consideration thereof agree hereby to release and forever discharge ACE, its Leadership Team, Business Team, officers, employees, agents, and any parties volunteering on behalf of ACE, from all actions, causes of action, injuries, claims, damages, ransom demands, costs or expenses of any kind, growing out of or related to any such Activities in which I participate. I understand that this is a full and complete release of all damages and injuries that I may sustain as a result of my participation in any of the Activities, regardless of the specific cause thereof.

Check to Agree: Medical Treatment Authorization and Power of Attorney *

In the event I suffer any injury or condition during my participation in the Activities, including transportation to and from the Activity, which may endanger my life, cause disfigurement, physical impairment, or undue discomfort or medical treatment is delayed, and as the result of which I am unable, in the opinion of my attending physician to make an informed decision regarding such treatment, and reasonable attempts to contact my emergency contact have been unsuccessful, I hereby appoint my Team Trip Leader or, in absence of a Trip Leader, ACE Management as my agent to act for me and in my name (in any way I could act in person) to make any and all decisions for the me concerning my personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate in (90) days or when, in the opinion of my attending physician, I am competent to make informed decisions regarding the need for medical treatment, or when the agent is able to contact my emergency contact, whichever occurs first.

Check to Agree: Authorization for Release of Information *

In the event I suffer an injury or condition during my participation in the Activities, including transportation to and from the Activity, I authorize my Team Trip Leader or, in absence of a Trip Leader, ACE Management to contact my emergency contact to advise them of my injury or condition, and to consult with them regarding my injury or condition.

Check to Agree: Video/Photography Release *

Regarding videos & photographs of myself taken at any ACE event, I give ACE permission to do the following for nonprofit use and without charge: use at the discretion of ACE, display at a service or event or be used in a multimedia presentation, reprint and distribute for any ACE publication with copyright to accompany photo when used, display on the ACE website, or use quotes and video clips on the ACE website or social media pages.

The undersigned agrees to the above Initialed sections and this agreement is binding on my Heirs, Successors and Personal Representatives. *

Type Full Name

Date

Signature *