TORREY PINES HIGH SCHOOL FOUNDATION

Liability Waiver, Release, and Medical Authorization

(To be completed by Participant Attending Field Trip Activity and a Parent or Guardian)
Please complete and return this form to the Torrey Pines High School Foundation. No person will be permitted
to participate in this activity if this form is not on file prior to beginning of the activity.

_________________________________________
Participant’s Name (print)
Date of Birth: ___________________________
Destination(s):
_______________________________________
_______________________________________
Activity: ____________________________
____________________________________
____________________________________

Departure Date: ____________________ Return Date: __________________

Departure Location: ________________________ Return Location: _____________________

The term “Fieldtrip” as used in this Liability Waiver, Release, and Medical Authorization (the Agreement”) shall mean the program
described above and all activities which are a part thereof, including but not limited to travel to, from, and during the activity and
attendance and/or participation in the activity.

1. Waiver of TPHSF’s Liability for Risks and Dangers.

The undersigned understand that there are certain dangers, hazards, and risks inherent in international and domestic travel, the activities
included in the Fieldtrip, and the use of any equipment or facilities related thereto, including but not limited to risks of injury, permanents
disability of death, property damage and severe social or economic loss, which may result from the actions, inactions, or negligence of
the Participant or others, weather conditions, conditions of equipment used, language barriers, differing social cultures, national and local
laws, sickness, strikes, natural disasters, civil unrest or hostilities, terrorist activities or acts of war, and that Torrey Pines High School
Foundation, its directors, officers, employees, and agents (hereinafter collectively (“TPHSF”)) do not assume responsibility for any such
personal injury, property damage or other loss. The undersigned further understand that the above risks are also associated with any
activities undertaken by Participant which are not activities included in the Fieldtrip. TPHSF does not assume responsibility for any
personal injury, property damage, or other loss suffered by Participant during such times.

Knowing the dangers, hazards, and risks described herein, or otherwise associated with participation in the Fieldtrip whether foreseen or
unforeseen, and in consideration of being permitted to participate in the Fieldtrip, the undersigned hereby, on behalf of the Participant’s
family, heirs, and personal representative(s), agree as follows:
A. To assume all risks and responsibilities surrounding Participant’s participation in the Fieldtrip including transit to,
during and from the Fieldtrip, and to forever discharge, release and waive any claims against TPHSF for any and all liability related to
any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature whatsoever which the
Participant may have or which may hereafter accrue to the undersigned, arising out of or related to any loss, damage, or injury, including
but not limited to suffering and death, that may be sustained by the Participant or by any property belonging to the Participant. This
release is intended to discharge the TPHSF from and against any and all liability arising out of or connected in any way with the
Participants participation in the Fieldtrip.

B. The undersigned understand that healthcare facilities may be minimal or absent in rural/remote areas and that all
types of health care, including for emergencies, may be difficult to find. The undersigned further understand that the Participant should
not expect the same type of health care as would be available in the Participant’s home country.

C. The undersigned understand and agree that TPHSF does not have medical personnel available at the location of the
Fieldtrip or during transportation or anywhere in the host country. In the event of illness or injury to Participant, the undersigned consent
to all routine and/or emergency medical treatments and/or services prescribed for Participant by the attending physician, surgeon, or
dentist, if any, and to the administration and performance of all examinations, treatments, anesthetics, operations, and other procedures
which are deemed necessary or advisable by the attending physician at the scene and/or at the hospital or other medical facility, if any.
The undersigned grant TPHSF permission to authorize routine and/or emergency medical treatment and that such action by TPHSF
shall be subject to the terms of this Agreement.
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 D. The undersigned are aware of all applicable personal medical needs of Participant. The undersigned agree that
TPHSF is not responsible for attending to any of the Participant’s medical or medication needs, that the undersigned assume all risk and
responsibility therefore, and that if Participant is required to be hospitalized during or after the Fieldtrip, TPHSF does not assume any
legal responsibility for payment of any costs related to such hospitalization or other care.

2. Trip Itinerary and Cancellation.

The undersigned acknowledge that the San Dieguito Union High School District (the “District”) has approved the Fieldtrip. The
District and TPHSF retain the right to cancel or change the itinerary of the Fieldtrip in the case of war, military actions, terrorist threats,
labor strikes, civil unrest, natural disasters, unstable environment or condition, or any other circumstances which the District or TPHSF
deems hazardous to the Fieldtrip participants or disruptive to the learning environment or any other element of the Fieldtrip. In the case
that the Fieldtrip is canceled or the itinerary is changed, the undersigned acknowledge and agree that they are solely liable for any and
all costs related thereto. TPHSF will refund to the undersigned only the funds that are refunded by the travel company, if any, engaged
to assist with the preparation of the Fieldtrip and any funds provided to TPHSF by the undersigned which remain unspent and
unencumbered.

3. Rules and Regulations.

The undersigned fully understand and agree that all persons, including the Participant, making the Fieldtrip are to abide by all
rules and regulations governing conduct during the trip. Any violation of such rules and regulations may result in the individual being
sent home at his/her own expense.

4. Pictures.
The undersigned agree that photographs, pictures, slides, movies, or other media coverage of Participant may be taken in
connection with Participant’s participation in the Fieldtrip without compensation from TPHSF and consent to the use of photographs,
pictures, slides, movies, or other media coverage for any legal purpose.

5. Legal Problems.
The undersigned acknowledge and agree that should Participant have or develop legal problems with any foreign national or
with any foreign government while participating in the Fieldtrip the undersigned will attend to the matter personally with the undersigned’s
own personal funds. TPHSF is not responsible for providing any assistance under such circumstances.

6. Travel Warning and Other Information.

The undersigned hereby acknowledge and agree that they have read and understand all Consular Information sheets, travel
warnings, and other announcements posted on the Web Sites of the U.S. State Department and the Centers for Disease Control
concerning the country or countries visited during the Fieldtrip.

7. Other Claims.
It is the express intent of the undersigned parties that this Agreement shall bind the Participant’s family, heirs, and personal
representative(s), and shall be deemed as a release, waiver, discharge, and covenant not to sue TPHSF. The undersigned hereby
waive all claims which they have now or may hereafter have against TPHSF, however caused, even if occasioned by or proximately
caused by negligence on the part of TPHSF, including without limitation all claims arising out of or in connection with Participant’s
participation in the Fieldtrip.

8. Governing Law.
This Agreement shall be governed by and construed in accordance with the laws of the State of California.

9. Entire Agreement.
The undersigned acknowledge and represent that the undersigned have become fully aware of the content of this Agreement
by reading it before signing it and that no oral representations, statements, or inducements, apart from the foregoing written statement,
have been made regarding the subject matter hereof.

10. Information Request.

The following information is requested for the knowledge of TPHSF and leaders participating in the Fieldtrip. The
collection of this information is to assist TPHSF and Fieldtrip leaders in conducting the Fieldtrip and responding to any
emergencies or other circumstances which arise during the Fieldtrip. The collection of this information in no way confers
liability upon TPHSF for medical, disability, dietary or other restrictions or limitations of the Participant.

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 A. ___ Check here if the Participant has a special medical or physical condition that the Foundation
should be aware of, and, if medication will be required on the trip concerning this condition. If you check the
space above to indicate that the Participant has a special medical or physical condition, attach a description of
that medical condition and/or physical disability hereto.

B. List any medication that the Participant must take while participating in the Fieldtrip and for each
medication listed provide the dosage and reason for the medication:
Name of medication Dosage Reason(s)
_________________________ _________________________ ________________________
_________________________ _________________________ ________________________
_________________________ _________________________ ________________________

C. Participant is allergic to the following medications:____________________________

_________________________________________________________________________.

D. Participant is allergic to the following foods, materials, etc.:_____________________

_________________________________________________________________________.

E. Primary Care Physician:___________________________________________________

Address: _____________________________ Phone No.: ( ) _____________
_____________________________________
_____________________________________

F. Emergency/contact______________________________________________________
Name
Address: ____________________________________________________________________

Phone No. ( ) ____________________ (work) ( ) ____________________(Home)

Email: __________________________

G. Participant’s Medical Insurance Carrier Policy Number

________________________ _________________________________

Address: ___________________________________________________________________

(Please attach a copy of your current, valid medical insurance card)

The undersigned acknowledge that they have carefully read this Liability Waiver, Release, and Medical
Authorization and understand and agree to its terms and understand its legal significance. This Liability
Waiver, Release, and Medical Authorization is freely given with the understanding that right to legal
recourse against TPHSF is knowingly given up in return for allowing Participant’s participation in the
Fieldtrip.

________________________ ______________________ ________________________

Participant Signature Date
(Please print)

________________________ ______________________ ________________________

Participant’s Parent or Guardian Signature Date
(Please print)

Note: A copy of this form must be kept with the primary Fieldtrip leader during the Fieldtrip, and a copy must be kept on file at the Foundation site.
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