Location

Los Angeles

Orange County

San Diego

Full Name *

Email *

Phone *

Dental Practice *

Emergency Contact #1 - Full Name *

Emergency Contact #1 - Phone Number *

Chronic Illness and/or Physical Limitations? *

Yes

Chronic Illness or Physical Limitations *

T-Shirt Size? *

Consent Agreement and Liability of Release

I agree By checking this box, I agree to obtain my own vaccinations at least 4-6 weeks prior to the mission date. I have also read and agreed to the Traveler Agreement and Release of Liability consent as stated below.

CONSENT AGREEMENT AND LIABILITY RELEASE: I hereby release SmileOnU, its officers, employees and Board of Directors from any and all liability for any acts or omissions related or unrelated for participating on-site mobile dental camps. I fully understand that the event has risks of accident or injury which may be caused by my own actions or inactions, the actions or inactions of SmileOnU. I will abide by the decisions of the leadership of SmileOnU. I understand this is a crucial element for the success and safety of all participants. I attest that the foregoing information that I have supplied is true and correct to the best of my knowledge. I understand that this is an application for “consideration” for the SmileOnU surf for charity event and does not guarantee me a position in the event. 1) COMMUNICATION: I agree that if I am accepted for this event, I will check my email often for communications and instructions. I will respond in a timely manner to all emails from SmileOnU to avoid jeopardizing my participation. 2) TRAVEL: I understand that I am responsible for all my transportation and accommodation for this event. 3) PICTURES and or VIDEOS: I agree and allow pictures, videos or any images of me to be used for the purposes of marketing for SmileOnU.