RTH Empower Her Masterclass Registration (to be filled out by an adult)

Student Information

First Name *

Last Name *

Age *

Please describe below any allergies or conditions we should be made aware of

How can best serve you and you daughter?

What specific outcomes or goals do you hope to achieve from participating in the EmpowerHer experience?

Emergency Contact (other than you) Name and Phone Number

Were you invited by a friend?

Yes

If you answered "yes" above please let us know who

A key component of the Empower Her Masterclass program is sending daily inspirational messages (Monday through Friday) directly to our students' phones. Do you consent to receiving these messages?

Yes

No thank you

Please provide the phone number below where you would like to receive the inspirational messages.

Parent or Legal Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Phone *

Waiver

1. I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and

2. IN CONSIDERATION OF the risk of injury (5A) that exists while participating in ANY Reaching TeenHearts SPONSORED ACTIVITY (hereinafter the "Activity"); and

3. IN CONSIDERATION OF my desire to for me or my dependent minor to participate in said Activity and

being given the right to participate in same;

4. I HEREBY release and forever discharge Reaching Teen Hearts , located at 2875 W. Ray Rd. Suite

6-101 Chandler, AZ. 85224, their affiliates, managers, members, agents, attorneys, staff, volunteers,heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of participating in the aforementioned

Activity.

5. I AM VOLUNTARILY PARTICIPATING in the aforementioned activity, and I am participating in the activity entirely at my own risk.

a. I am aware of the risks associated with participating in this activity, which may include, but are not limited to: physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death.

b. I understand that these injuries or outcomes may arise from my own or others’ negligence, conditions related to travel to and from the activity, or from conditions at the activity location(s). Nonetheless, I assume all related risks, both known and unknown to me, of my participation in this activity.

6. I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.

7. I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize Reaching Teen Hearts to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

8. I HEREBY ACKNOWLEDGE that I have carefully read this "Waiver and Release" and fully understand that it is a Release Of Liability. I expressly agree to release and discharge Reaching Teen Hearts and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or calls for action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against the Reaching Teen Hearts for personal injury or property damage.

9. To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of the Reaching Teen Hearts, its agents, and employees.

10. I agree that this Release shall be governed for all purposes by Arizona law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements. All claims shall be mediated or litigated in the state courts of Arizona.

11. In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.

12. THIS WAIVER AND RELEASE OF LIABILITY shall remain in effect for the duration of my participation in the activity, during this initial and all subsequent events of participation. I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this Release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.

I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this Release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will. I hereby grant and authorize Reaching Teen Hearts the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all video/photos taken of me to be used in and/or for any lawful purpose. This authorization extends to all languages, media, formats and markets now known or later discovered. This authorization shall continue indefinitely, unless I otherwise revoke this authorization in writing. I waive the right to inspect or approve any finished product in which my likeness appears. I agree that I have been compensated for this use of my likeness or have otherwise agreed to this release without being compensated. I waive any right to royalties or other compensation arising or related to the use of the video. I understand and agree that these materials shall become the property of Reaching Teen Hearts and will not be returned. I hereby hold harmless and release Reaching Teen Hearts from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

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Signature

Clear