Lao Women Association Registration Form

Goal: LWAW Civic Engagement Technology Literacy Camps at the Filipino Community of Seattle (provided by S.P.I.N.)

Date and Time: Starts Spring 2015 April on Sunday (Actual Dates will be notified to accepted registrations)

Method of transportation: None, Own transportation

Cost: $0 FREE TO LWAW Community (Donations welcome)

Full Name *
Full Name
Birthdate *
Birthdate
Gender *
Address *
Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Emergency Contact
Full Name *
Full Name
Address (If different from student)
Address (If different from student)
Contact Phone *
Contact Phone
What is your Ethnicity or Race? *
Please check all the categories that apply?
Are you limited English speaking? *
Are you an immigrant, refugee, or new arrival to the US? *
Are you a person with disability? *
How many in your household are under 18 years old? *
Do you have any computer experience? *
Do you own a smartphone (iphone, android, windows)? *
Medical Information
IN CASE OF MEDICAL EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT MY EMERGENCY CONTACT. IN THE EVENT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY THE DIRECTOR TO HOSPITALIZE, SECURE TREATMENT FOR, AND TO ORDER INJECTION, ANESTHESIA OR SURGERY FOR ME. I REMAIN FULLY RESPONSIBLE FOR ANY LEGAL OR FINANCIAL RESPONSIBILITY THAT MAY RESULT FROM ANY PERSONAL ACTIONS TAKEN BY MYSELF.I HEREBY WAIVE AND RELEASE ANY CLAIM AGAINST THE LOA WOMEN'S ASSOCIATION OF WASHINGTON, FILIPINO COMMUNITY OF SEATTLE, SPIN, AND CITY OF SEATTLE SYEP INTERNS, PROGRAM VOLUNTEERS, FCS BOARD OF DIRECTIONS, ADMINISTRATION, AND GENERAL STAFF FOR ANY INJURIES SUFFERED BY ME DURING SUCH ACTIVITIES WHETHER CAUSED BY THE NEGLIGENCE OF THE DESIGNATED SUPERVISOR OR OTHERWISE. IN THE EVENT OF AN INJURY SUFFERED DURING THE TRANSPORTATION TO AND FROM THE SITE, I AGREE TO LOOK SOLELY TO THE INSURANCE CARRIER PROVIDING INSURANCE ON THE TRANSPORTING VEHICLE FOR COMPENSATION.
Please list in detail
PROGRAM RELEASE AND INDEMNITY AGREEMENT
The above information is complete and true to the best of my knowledge. I also confirm the authorization and consent detailed within this document, including but not limited to other activity participation, photos, and emergency contacts. I hereby release, discharge, and covenant not to sue Filipino Community of Seattle, its Board, employees, volunteers, and partner agencies and their representatives from all liability to me for all claims, demands, losses, or damages on account of any injury or damage to property caused or arising from my participation in the program. I may be photographed (still and video) for FCS SPIN Camp partners' and community outreach publications.
READ BEFORE SIGNING *
READ BEFORE SIGNING
Print Name
Date Signed *
Date Signed
Electronic Signature *
Electronic Signature