Missouri Personal Liability And Medical Release Form

Missouri TSA
1
MoTSA
FORM
PERSONAL LIABILITY and MEDICAL RELEASE FORM
Read the other side of this form. Then, complete the entire form. Type or print clearly. You must wear your name badge to gain entry
to conference functions.
1
Local TSA Chapter:
Parents’ Names:
Complete this Check one: ? Level I (grades 6-9)
entire section.
? Level II (grades 9-12)
Parents’ Telephone Number (area code required):
(
Name of Teacher/Adult accompanying participant to conference, if
applicable:
Participant’s Home Address:
School where your Technology Education course is taught:
City:
State:
ZIP Code:
Home Telephone Number (area code required):
(
Event
Complete this
section.
All complete
this section.
Mailing Address of above school:
City:
State:
ZIP Code:
)
Age:
2
)
Participant’s Name (First, Last) as it should appear on name badge:
Date of Birth (MM/DD/YY):
Check one:
?
?
?
?
Check one:
? Male
? Female
? State Officer Training
? State TSA
National TSA Conference
? District Contest
Executive Board Meeting
State Fall Leadership Conf.
School Telephone Number (area code required):
(
)
Contest
Abbreviation:
Contest Name:
Events in which contestant is registered:
Other (please specify)
______________________________
Check one:
? Contestant
? Advisor (Teacher)
? District Officer
? State Officer
? Lead Chapter Advisor
? Principal
?
?
? Participant
? Observer / Other
________________
?
3
Name of Person to Contact in event of emergency:
Family Physician:
(
Contact Person’s Telephone Number (area code required):
Emergency
Information
(
)
Complete this Contact Person’s Street Address:
entire section.
City:
State:
ZIP Code:
Name of Person Responsible for Your Medical Bills (Guarantor):
4
Guarantor’s Relationship to
Participant:
Photocopy
Guarantor’s Employer:
your insurance
card and
attach the
Employer’s Address:
copy to the
back of this
form
Physician’s Telephone Number:
City:
)
Do you have any known allergies?
If “yes,” please list:
? No
? Yes
Do you have a history of allergies, heart
condition, diabetes, asthma, epilepsy, rheumatic
fever or other existing medical conditions?
If “yes,” please explain:
? No
? Yes
Are you taking medication?
Yes
If “yes,” please explain:
? No
?
Do you have any physical restrictions?
If “yes,” please explain:
? No
? Yes
Guarantor’s Social Security Number
(Optional):
Employer’s Telephone Number:
(
)
State:
ZIP Code:
Insurance Company:
Insurance Company’s Address:
If you don’t
have
Insurance,
sign where
noted
City:
State:
ZIP Code:
If you do not have any medical insurance, sign here:
Insurance Plan Number:
Insurance Group Number:
Insured I.D. Number:
5
When did you last have a tetanus shot?
Signature of participant
Date
PARTICIPANTS______________________________________________________________
CHECK HERE IF YOU ARE OVER 18 AND CAN SIGN FOR YOURSELF: ?
Signature of Participant
Date
Having read and understood completely the Personal Liability and
Medical Release, the Code of Conduct, and the Photography and
Sign the
______________________________________________________________
Sound Release agreements on the other side of this form, I, by
Signature of Parent or Guardian (mandatory if under age 18)
Date
agreement signing at right, do hereby agree to abide by these in their entirety
and completely release Missouri TSA, Inc.
THIS COMPLETED FORM MUST BE TURNED IN, OR PARTICIPANT WILL NOT BE ALLOWED TO ATTEND.
Rev. 11/26/01
Missouri TSA Personal Liability
and Medical Release Form
I hereby agree to release the Technology Student
Association, Inc and the Missouri Technology
Student Association, its representatives, agents,
servants and employees from liability for any
injury to the named person, resulting from any
cause whatsoever occurring to the named person
at any time while attending a Missouri TSA
activity as indicated on the other side of this
page, including travel to and from the
conference or activity, excepting only such
injury or damage resulting from willful acts of
representatives, agents, servants, and employees.
I do voluntarily authorize the Missouri TSA
activity Medical Services Coordinator, assistants
and/or designees to administer and/or obtain
routine or emergency diagnostic procedures
and/or routine or emergency medical treatment
for the named person as deemed necessary in
medical judgment. Parents or guardians of the
participant will allow emergency medical
treatment to be administered as needed. Any
further treatment will require parental or
guardian consultation.
I agree to indemnify and hold harmless the
T echnology Student Association, Inc the
Missouri Technology Student Association, and
said Medical Services Coordinator and/or
assistants and designees for any and all claims,
demands, actions, rights of action, and/or
judgments by or on behalf of the named person
arising from or on account of said procedures
and/or treatment rendered in good faith and
according to accepted medical standards.
Having read and understood completely the
“Code of Conduct” of the Technology Student
Association, Inc. I do hereby agree to follow the
procedures and practices described. I fully
understand that this is an educational activity
and will, to the best of my ability, apply myself
for the purpose of learning and will uphold at all
times the finest qualities of a person representing
the Technology Student Association, Inc.
NOTE: All persons under legal age must have a
parent or guardian sign this form (see other side).
If you are age 18 or older, please indicate that on
the other side of this form. Otherwise, this form
will be returned for a parent or guardian’s
signature. All participants must sign this form.
PARTICIPANTS: Be sure that you understand
the “Code of Conduct.” Any person violating
these rules may be sent home at their own
expense, may cause other participants or
contestants from their school to be sent home,
or may otherwise disqualify their chapter
members from participating in a Missouri TSA
Activity including the Missouri TSA State
Conference.
Code of Ethics Agreement
The Missouri TSA activities are designed to be
an educational function and all plans are made
with that objective. The Conferences represent
Missouri TSA’s most significant meetings of the
year, many students attend from all over the
state. It is approved as a major educational
activity by the Nat ional Association of
Secondary School Principals and International
Technology Education Association.
Missouri TSA wants every person to have an
enjoyable experience with every attention paid
to safety and comfort. All participants will be
expected to conduct themselves in a manner best
representing the nation’s greatest student
association.
In order that everyone may receive the
maximum benefits from their participation, the
“Code of Conduct,” as established by the
Missouri TSA Executive Board, must be followed
at all times.
Note that attendance is not mandatory. By
voluntarily participating, you agree to follow the
official conference rules and regulations or
forfeit your personal rights to participate. We
are proud of our students and know that by
signing this “Code of Conduct” you are simply
reaffirming your dedication to be the best
possible representative of your school and
chapter.
1. I will, at all times, respect all public
and private property, including the
hotel or motel in which I am housed.
2. I will spend each night in the room of
the hotel or motel to which I am
assigned.
3. I will strictly abide by the curfew
established and shall respect the rights
of others by being as quiet as possible
after curfew.
4. I will not remain in the sleeping room
of the opposite sex unless the door is
completely open at all times, unless the
person is my legal spouse.
5. I will not use alcoholic beverages. I will
not use drugs unless I have been
ordered to take certain prescription
medications by a licensed physician. If I
am required to take medication, I will,
at all times, have the orders of the
physician on my person.
6. I will not leave the hotel or motel
without the express permission of my
local chapter advisor. Should I receive
permission, I will leave a written notice
of wh ere I will be.
7. My conduct shall be exemplary at all
times.
8. I will keep my advisor or state TSA
advisor informed of my whereabouts at
all times.
9. I will, when required, wear my official
identification badge.
10. I will respect official TSA dress and not
smoke wh ile wearing it.
11. I will attend, and be on time for, all
general sessions and activities that I am
assigned to and registered for.
12. I will adhere to the dress code at all
required times.
Violations and Penalties
I agree that if, for any reason, I am in violat ion
of any of the rules of the conference or activity
I am attending, I may be brought before the
appropriate discipline committee for an analysis
of the violation. I also agree to accept the
penalty imposed on me. I understand that any
penalty and reasons for it will be explained to me
before it is carried out. I further realize that the
severity of the penalty may increase with the
severity of the violation, even to the extent of
being immediately sent home at my own
expense.
1. Violations of Items 1 through 6 of the
“Code of Conduct” will be grounds for
disqualification, immediate removal from
office or competition and relinquishment of
awards and recognition. In addition, the
violator will be sent home at his or her own
expense. Notification of the violat ion and
the action taken will be sent to the
participant’s local school district
administrator and parents or guardians. The
participant’s entire voting delegation could
be unseated due to the violation, and the
candidates or competitors from the
participant’s local school and chapter could
be disqualified as well.
2. Violations of Items 7 through 12 will result
in a warning and reprimand. Notification of
the violation and the action taken will be
sent to the participant’s local school district
administration and parents or guardians.
Repeated violations of Items 7 through 12
may result in the participant being sent
home at his/her own expense.
It is within the spirit of being a proud and
meaningful member of TSA that I agree to these
rules of conduct by signing my name on the
other side of this page.
Photography and Sound Release
I hereby grant the Missouri Technology Student
Association permission to make still or motion
pictures and sound recordings, separately or in
combination, and also give a production
company approved by the Missouri Technology
Student Association permission to use the
finished silent or sound pictures, and/or sound
recordings as deemed necessary.
Further, I so hereby relinquish to the Missouri
Technology Student Association all rights, title,
interest in, and income from the finished sound
or silent motion pictures, still pictures, and/or
sound recordings, negatives, prints,
reproductions, and copies of the originals,
negatives, recording duplicates and prints, and
further grant the Missouri Technology Student
Association the right to give, sell, transfer,
and/or exhibit the same to any individual,
business firm, publication, television station,
radio station or network, or governmental
agency, or to any of their assignees, without
payment or other consideration to me.
My agreement to perform under camera,
lighting, and stated conditions is voluntary and I
do hereby waive all personal claims, causes of
action, or damages against the Missouri
Technology Student Association and the
employees thereof, arising from a performance
or appearance.
MoTSA Form 1 11/26/01