Medical Release Form
This section collects medical information designed to assist FoNA when seeking authorized medical treatment for you should that become necessary during the 2019 FoNA Impact Trip.
Your Health History
Consent For Treatment
I agree to notify FoNA personnel of any pre-trip injury or illness that may require medical attention or assistance during the 2019 FoNA Impact Trip.
If an emergency arises while particpating in the 2019 FoNA Impact Trip, I recognize that medical treatment may be necessary.
In case of an emergency, I give permission to FoNA personnel to secure medical attention and treatment. This may include selection of medical professionals, hospitalization, and treatment options such as injections, anesthesia, and surgery. I agree to bear the cost of this treatment.
I agree to assume all risks related to seeking and receiving medical treatment. I also agree to hold harmless FoNA and its partners from all liabilities, claims, demands, and causes of action that may arise from my participation in the 2019 FoNA Impact Trip.
Over-the-Counter Medications Release
This section authorizes FoNA personnel to dispense/adminster over-the-counter medications to you. In all cases, the manufacture's recommended dosage of these medications will be followed.
Should an adverse reaction occur after the administration of an over-the-counter treatment, I give permission to FoNA personnel to secure medical treatment from any hospital, licensed physician, or medical personnel deemed necessary for immediate care.
I release FoNA, its officers, and representatives from all liability resulting from the administration of over-the-counter treatments. These releases are binding upon my heirs, executors, administrators, and assigns.
I also agree to indemnify, hold harmless, and defend FoNA and its governing board, officers, and representatives from claims resulting from injuries, damages, and losses sustained by me as related to the administration of over-the-counter medication.
And finally, I agree to be responsible for payment of medical services provided in connection with administration and treatment of over-the-counter medications.
From time to time, FoNA will record activities during the 2019 FoNA Impact Trip. Recording methods could include film, videotape, magnetic tape, digital or other recording medium. These recording may be duplicated and distrubuted to the public.
FoNA General Liability Release
I release and agree to hold harmelss FoNA and any related agency or partner from liability, injury damages loss, accidents, delay or irregularity related to the my participation or involvement in 2019 FoNA Impact Trip.
I have been advised and understand that the 2019 FoNA Impact Trip may involve unusual risks to participants. These risks may include dangers related to air, land, and sea travel, disease, civil insurrection or warfare, post warfare hazards, and exposure to extreme heat and humidity with no air conditioning available.
I understand that this list of potential dangers is not exhaustive, rather, it is illustrative of the types of danger that could be encountered.
I understand that this release binds me, my heirs, representatives, and assignees.
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