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FORM NOW CLOSED - BMUN 68 Medical and Photo Release Form and Liability Release Waiver

THIS FORM IS NOW CLOSED FOR BMUN 68. IF YOU AND/OR YOUR CHILD HAS NOT FILLED OUT THIS FORM YET, THEY WILL BE ASKED TO DO SO AT REGISTRATION.

PLEASE DO NOT FILL OUT THIS FORM.

This medical release form helps us ensure the safety of your child while at conference. In the event of an emergency, this medical information will help us better keep your child safe. Please be assured that this sensitive information will be kept entirely confidential and will only be used in the event of an emergency during conference by the members of the Secretariat.

If you do not feel comfortable filling out this form, please email Ashwin Srikanth at info@bmun.org.

Parent / Guardian Information

First Name *

Last Name *

Phone *

Email Address *

Address

Address Line 2

City

State

Zip

Liability Release Form

Please read carefully before signing.

In consideration for my participation and the participation of my child in Berkeley Model United Nations 67th Session to be operated by the Berkeley Model United Nations Secretariat, Inc., a California non-profit corporation, I agree to:*
Assume all risk of injury to my child and all risk of damage to or loss of property arising out of my child’s participation in this program;
Release, discharge and waive any and all responsibility of the University of California, the ASUC, and the Berkeley Model United Nations Secretariat from and against liability for any injury, including death, and for damage to or loss of property which may be suffered by my child arising out of or in any way connected with the participation in this program;
Indemnify and hold harmless the University of California, the ASUC, and the BMUN Secretariat, their officers, agents, and employees from against all liability, claims, demands, actions, loss and damage arising out of my child’s participation in said Berkeley Model United Conference;
Agree to the Berkeley Model United Nations Secretariat use of photo/video of my child on BMUN affiliated sites, including our bmun.org website, and official BMUN mailings;
Obey University of California, Berkeley campus' Tobacco Free Policy.

IN CASE OF EMERGENCY NOTIFY (first and last names): *

Emergency Contact Address*

Emergency Contact Phone Number*

Legal Guardian #1*

Legal Guardian #1 Address*

Legal Guardian #1 Phone Number*

Legal Guardian #2

Legal Guardian #2 Address

Legal Guardian #2 Phone Number

Minor's Physician Name

Minor's Physician Address

Name of Medical Insurance Provider*

Policy #*

If your child has a MEDICAL PROBLEM or is taking MEDICATION, please list all that would be important for us to be aware of, please indicate here:

If your child is ALLERGIC to anything, please list all that would be important for us to know:

If your child requires accessibility accommodations due to disability, please indicate here:

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR*
(I) (We), the undersigned parent(s)/guardian(s), do hereby authorize University of California, Berkeley Health Services or attending medical personnel as agent(s) for the undersigned to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions Code §2000 et. seq.; or any X-ray examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any dentist licensed under the provisions of the Dental Practices Act, California Business and Professions Code §1600 et. seq. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician or dentist, in the exercise of his/her best judgment, may deem advisable. This authorization is given pursuant to the provisions of California Family Code §6910. (I) (We) hereby authorize any hospital, which has provided treatment to the above-named minor pursuant to the provisions of California Family Code §6910, to surrender physical custody of such minor to (my) (our) above-named agent(s) upon the completion of treatment. This authorization is given pursuant to California Health and Safety Code §1283. These authorizations shall remain effective until March 4th, 2018, unless sooner revoked in writing delivered to said agent(s).

Media Release Form

ASSIGNMENT OF PHOTOGRAPHIC, MOTION PICTURE, VIDEO, AND SOUND RECORDING RIGHTS*
I, hereby authorize THE REGENTS OF THE UNIVERSITY OF CALIFORNIA (the “University”) and its officers, agents, and employees, to photograph, record, film, or videotape me. I understand that any photograph, sound recording, motion picture, or video taken of me under this assignment is for the purpose of collecting and/or representing factual information in the interest of serving the University of California’s mission of research, education, and public service, and for promoting the public good. I hereby assign to the University all rights, title, and interest, including copyright, in and to any and all such photographs, sound recordings, motion pictures, or videos, and I hereby irrevocably authorize the University, its officers, agents, and employees, without limitation, to reproduce, copy, sell, exhibit, publish, or distribute, in any medium now known or later developed, any and all such photographs, sound recordings, motion pictures, or videos in perpetuity for the purposes expressed above. I further release and forever discharge the University, its officers, agents, and employees from any and all claims and demands arising out of or in connection with the use of said photographs, sound recordings, motion pictures, or videos, including but not limited to any and all claims for invasion of privacy, defamation, or infringement of copyright. I have read and understood the provisions of this agreement, and understand that I am free to obtain advice from legal counsel of my choice, at my expense, to interpret these provisions. By signing below, I acknowledge that I have freely and voluntarily entered into this agreement.
If you do not agree to this statement, please check this box

Copyright Assignment*
I also hereby assigns and transfers to Berkeley Model United Nations, its successors and assigns, the entire right, title, and interest in and to all copyrights in the Work; all registrations and copyright applications relating thereto and all renewals and extensions thereof; all works based upon, derived from, or incorporating the Work; all income, royalties, damages, claims and payments now or hereafter due or payable with respect thereto; all causes of action, either in law or in equity for past, present, or future infringement based on the copyrights; and all rights corresponding to the foregoing throughout the world.
If you do not agree to this statement, please check this box

Certification*
For subjects under 18 years of age: I hereby certify that I am the parent or guardian of the person named above, and I do hereby give my consent without reservation to the foregoing on behalf of him or her.

Delegate Information

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

First Name

Last Name

Date of Birth

Delegation Name*

BMUN Committee*

Committee Position (i.e. Country, person, etc.; exactly how it appears on Huxley)*

Delegate Email (the same email address used for Huxley, paying attention to capitalization)*

Delegate Address*

Delegate Phone Number*

Delegate Initials:*

Date of Delegate Initials:*

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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.