Name *

First Name

Last Name

Phone *

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I am a current student enrolled at Point Loma Nazarene University. *

This trip is for current PLNU students only. Non-PLNU students are not eligible for this trip

Yes, I am a current PLNU Student.

I am currently 18 years old or older. *

If you are under 18, please pause your registration and email lomaoutside@pointloma.edu for more information.

Yes, I am 18 years old or older

I understand that such activity, including my operation of equipment necessary for participation in the activity, may expose me to certain risks of injury, death, or damage to my property. Including but not limited to hazards of travel, accident, illness, or acts of God. I also understand and agree that a situation may arise during an activity which may be beyond control. I fully realize the dangers of participating in an activity of this type and I voluntarily assume all risks associated with such participation. I further understand and agree that such activity and/or my participation in the activity may be recorded (via photographs, video, sound recording or otherwise), and such recordings may include my name, image, voice, statements or likeness (“AV Materials”). In consideration for PLNU’s agreement to allow me to participate in the activity, I hereby unconditionally and irrevocably release, waive and forever discharge PLNU and its affiliates, and their respective officers, employees, trustees, students, faculty, representatives, agents, successors and assigns ("Released Parties"), from any and all claims, disputes, damages, losses, liabilities, attorney’s fees and other costs, known or unknown, foreseen or unforeseen, accrued or unaccrued, arising out of or related to (i) the structure or operation of the activity, (ii) my participation in the activity, (iii) any personal injuries, death, property damages, or other liabilities that are caused or contributed to by me and/or that are incurred by me that are in any way related to the activity or my participation in the activity, and/or (iv) the Released Parties’ use of any AV Materials [subclauses (i) – (iv) are “Covered Items”). I also hereby indemnify, defend and hold harmless the Released Parties from any and all claims, liabilities, damages, disputes, losses and other expenses, including without limitation attorneys' fees and costs, incurred by or asserted against Released Parties, whether or not a lawsuit or other proceeding is filed (“Claims”), that in any way arise out of or relate to any of the Covered Items. I agree that I will not enter into any settlement of such Claims without Released Parties’ prior written consent. I further agree that Released Parties, at their expense, have the right to retain separate independent counsel to assist in defending any such Claims. I also agree that the provisions of this Agreement shall survive the occurrence of the activity. *

I have read, understand, and affirm.

I hereby grant to the Released Parties a perpetual, worldwide, royalty free, fully paid up, irrevocable, exclusive, sublicensable and transferrable right and license to display, modify, broadcast, publicly perform, reproduce, prepare derivative works of, distribute and/or otherwise use in any way any of the AV Materials in any media, in any manner, for any purposes and with such frequency as any of the Released Parties shall determine in their sole discretion without compensation to me and without further authorization by me. There is no time limit or geographical limitation on Released Parties’ use of such AV Materials. *

I have read, understand, and affirm.

I agree that it is my sole responsibility to be familiar with the physical and/or mental demands associated with the above-named activity. With these demands in mind, I hereby declare that I am physically capable of participating in the above-named activity, and that I have no physical or medical condition which, to my knowledge, would interfere with my ability to participate in this activity or endanger myself or others who participate in this activity. I also agree to abide by any established rules or regulations while participating in this activity. I also agree that I will not be compensated by Point Loma Nazarene University for my participation in this activity. *

I have read, understand, and affirm.

In the event of accident or illness of an emergency nature, and because I may be unable to select or approve of the required medical treatment, I hereby authorize event organizers or representatives of Point Loma Nazarene University to arrange for such care as is available and necessary; and do further release and forever discharge the providers of such care and Point Loma Nazarene University, and its officers, agents, employees, auxiliaries from any and all claims, demands and causes of action arising out of said authorization. *

I have read, understand, and affirm.

I am aware that Point Loma Nazarene University does not provide medical insurance coverage and therefore take full responsibility for my personal insurance. I understand that all expenses, charges, or costs which might result from injury or illness are my responsibility. *

I have read, understand, and affirm.

HEALTH INFORMATION *

In order to prepare for a medical emergency on the trip, Point Loma Nazarene University requests the following information: Please check all that apply:

Asthma

Diabetes

Head Injury

Heart Condition(s)

Joint Injury

Seizure/Epilepsy

Spinal/Back Injury

Allergy requiring Epi-Pen prescription

N/A

Dietary Restrictions *

Vegetarian

Vegan

Dairy Free

Gluten Free

N/A

Allergy Medications *

I understand that Loma Outside requires participants to bring their own medication on trips including Asthma inhaler, Epi-pen, etc. If I have one of these medications, I will bring it with me on the day of the trip!

I understand and will bring my medication.

Not Applicable

Emergency Contact *

First Name

Last Name

Emergency Phone Number *

(###)

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Insurance Information

In order to participate, students must be covered by insurance, either personal, family, or university. Are you covered by insurance?

Yes and I will bring proof of insurance to the ARC prior to the trip

Refund Policy *

I have read and agreed to the refund policy which states: Full refunds are available for all Loma Outside and Outdoor Leadership training trips until 8:00pm the Friday 2 weeks prior to the trip. A 50% refund is available until 8:00pm the Monday the week of the trip. After this date, all funds are forfeited with no exceptions. In the event of a cancelled trip, a full refund will be issued to all participants.

I have read and understand.

Trips are Non-Transferable *

I understand that ALL trip spots are Non-transferable. I will not sell my spot to another student if I am unable to attend a trip I have already signed up for, but will accept the refund policy.

I have read and understand.

Please sign by typing your name below. *

First Name

Last Name

Date *

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