SILICON VALLEY URBAN DEBATE LEAGUE

www.SVUDL.org • info@SVUDL.org • (408) 337-2493

Travel Authorization & Release

Dear Parent/ Guardian:

Student Name: ______________________________________________ Age: _______________ Email Address: _______________________________

Home Address: ______________________________________________________________________________ City: ____________ Zip: __________

Student’s Phone: _____________________________ School: _____________________________________________________________________,

has my permission to participate in the activity shown below:

Event: Summer Debate Institute 2019

Date of Event: July 22nd to July 26th, 2019 from 9am to 7pm

Location of Event: Yerba Buena High School, 1855 Lucretia Ave, San Jose, Ca 95122

Contact Person(s): Jenet Manuel – 408-7442870, Rolland Janairo – 401-4197603, Robert Burns – 314-6199336, Janet
Escobedo – 408-4309642, Kwodwo Moore – 408-4309079, Jimi Morales – 408-6659964

Logistics: Air and land transportation, lodging, debate registration and meals will be covered by SVUDL. Students are welcome to bring spending money
for souvenirs. Detailed logistical information will be sent out via email on or before July 17, 2019.

_______(Initial) I am aware that during any trip, camp or excursion injury or death may occur from hazard, including but not limited to, hazards of
accidents or illness in place without medical facilities, hazards created by the forces of nature, and hazards of travel by air, train, bus, automobile and
walking. I am voluntarily permitting my Students to participate in the above activity with the knowledge of the hazards involved and I agree to accept any
and all risks of injury or death.

_______(Initial) I declare that my child is in good academic standing and acknowledge he/she will miss _____ day(s) of school.

_______(Initial) I hereby give SVUDL the permanent right and permission to copyright and/ or publish, reproduce or otherwise use my child’s, voice and
likeness and/ or written material, photographs and audio-visual about my child for instruction, art, art, advertising or any other lawful purpose.

_______(Initial) I agree that my child will abide by the rules and regulations of the Silicon Valley Urban Debate League during the entire trip, camp or
excursion. I agree that for the duration of this Trip, my child will not engage in behavior injuries to any other person, whether mentally or physically.

In consideration of Student’s participation in the activity described above, I agree that I, my heirs, spouse, guardians, legal representatives and assigns
will not make a claims against, or sue Silicon Valley Urban debate League, its officers, agents or employees for injury, death or property damages arising
from the negligence or participation in the activity described above.

In addition, I release and discharge Silicon Valley Urban Debate League, its officers, agents and employees from all actions, claims, or demands that I,
my heirs, guardians, legal representatives or assigns now have or may later have injury, death or property damage resulting from Student’s participation
in the activity described above.

This Agreement and Release of Liability are intended to be binding upon heirs, guardians, legal representatives and assigns.

I, __________________________________________________________ (Parent/ Guardian), HAVE CAREFULLY READ THIS DOCUMENT AND

FULLY UNDERSTAND ITS CONTENTS. I HAVE EXPLAINED THIS DOCUMENTS TO MY CHILD/WARD AND REPRESENT THAT MY CHILD/WARD
UNDERSTANDS THE CONTENTS OF THIS DOCUMENT. I AM AWARE THAT HIS IS A RELEASE OF LIABILITY AND I SIGN IT VOLUNTARILY.

_______________________________________ _______________________

Parent/ Guardian’s Signature Date

1
 SILICON VALLEY URBAN DEBATE LEAGUE
www.SVUDL.org • info@SVUDL.org • (408) 337-2493

If Students is under the age of 18:

Name of Parent/ Legal Guardian: _______________________________________________________________________________________________

Parent/ Legal Guardian’s Address: ______________________________________________________________________________________________

Parent/ Legal Guardian’s Home Telephone No.: ___________________________________________________________________________________

Parent/ Legal Guardian’s email address: _________________________________________________________________________________________

MEDICAL AUTHORIZATION -

I declare and confirm that my child is in good medical and physical condition and that participation in the activities of this trip does not pose any danger to
my child’s health.

The undersigned representing him/ herself, or on behalf of the child named above, hereby authorizes an agent of Silicon Valley Urban Debate League to
consent to any medical, dental, surgical, or hospital care, treatment or diagnosis for the above named child, under the care or supervision of any licensed
physician, surgeon or dentist. I further agree to pay for any medical, dental, surgical, or hospital care, treatment, or diagnosis provided the above named
child pursuant to this authorization, and to defend, indemnify and hold harmless Silicon Valley Urban Debate League from any actions, claims, or
demands that I, my heirs, guardians, legal representatives or assigns, or any other person or entity may now have or may later have, including but not
limited to claims of injury, death, property damage, or medical bills and expenses resulting from care, treatment, or diagnoses provided to the above
named child pursuant to this authorization.

Student’s Physician: __________________________________________________________ Email Address: __________________________________

Physician’s Address: _________________________________________________________________ Telephone No.: ___________________________

Medical Insurance: ___________________________________________________________________ Group Number: __________________________

Subscriber's Name: ___________________________________________________________________ ID Number: _____________________________

Employer’s Address: _________________________________________________________________________________________________________

Please list any, allergies, or special medical conditions of Student:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Dietary and/or Religious Restrictions:

( ) None ( ) Vegetarian ( ) Vegan ( ) Other: __________________________________________________