Participant Name *

First Name

Last Name

Select Program *

8th Grade Paleos- June 30-July 8

Shindig Allstars (High School) July 23-July28

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Cell Phone *

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Participant Cell Phone

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Particpant Date of Birth *

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Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 Phone *

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Emergency Contact 2 *

First Name

Last Name

Emergency Contact 2 Phone *

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Name on Participant's Insurance Policy *

First Name

Last Name

Authorization for Emergency Medical Care *

I hereby give my permission to the staff of Dinosaur Discovery Adventures to call for medical or surgical care in the event of an emergency. I agree to accept the expenses of any emergency treatment, ambulance, or other associated expenses deemed prudent to assure safety and well being.

Primary Physician Phone

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Media Permisions

We take a lot of pictures and video of your family participating in our programs. We'd like your permission to use those photos in our marketing and to post videos online so other families can share the expereience. Please give us your permission to use photos and videos of your family by checking the box below

I give permission and consent for videos and photographs of my family to be taken during this Dinosaur Discovery Adventure program. I further give permission and consent that any such photographs and videos may be published and used by John Hankla, Dinosaur Discovery Adventures and it's agents, to illustrate and promote our programs and share the experience with families, friends and Dinosaur enthusiasts.

Liability Waiver and Assumption of Risk Agreement *

In consideration of my use of the premises of Paleo Park and my involvement with John Hankla and the Dinosaur Discovery Adventures field school in Paleontology, I for myself, my heirs, personal representative or assigns, do hereby release, waive, discharge, and covenant not to sue John Hankla, Kristen Zerbst Stauffer, Their trustees, directors, officers, employees, volunteers and agents from liability from any and all claims including negligence resulting in personal injury, accidents, or illnesses (including death) and property loss arising from use of premises. The Dinosaur Discovery Adventures curriculum carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I have read the previous paragraphs and I know and understand and appreciate these and other risks are inherent in the activity I am participating in. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. I also agree to indemnify and hold harmless John Hankla, Kristen Zerbst Stauffer, their trustees, directors, officers, employees, volunteers and agents from any and all claims, actions, suits, costs, expenses, damages and liabilities including attorney fees as a result of this use of premises. The undersigned further expressly agrees that the forgoing waiver and assumption of risk agreement is intended to be as broad and inclusive as is permitted by the law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect

I have read this waiver of liability, assumption of risk, and indemnity agreement, and fully understand its terms. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Parent Name *

First Name

Last Name

Today's Date *

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