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PARTICIPANTWAIVER

TheundersignedparticipantagreesthatalluseoftheHacktheHoodfacilitiesandall
participationineventsisundertakenathis/hersolerisk.TheparticipantagreesthattheHackthe
Hoodsite,staff,independentlycontractedstaffandteachers,andemployees,isnotresponsible
for,andisnotsubjectto,anyclaim,demand,orcauseofactionwhatsoeverforanyinjurytothe
participant,includingwithoutlimitationanyresultingfromactiveorpassivenegligenceonthe
partoftheHacktheHoodstaff/teachers,itsowners,operators,agents,oremployees.The
participant,forhimself/herselfandonbehalfofhis/herexecutors,administrators,heirs,assigns
andsuccessors,herebyexpresslyforeverreleasesanddischargestheHacktheHood
staff/teachers,BoardofDirectors,itsowners,operators,agents,andemployeesfromanyandall
suchclaims,demands,andcausesofactions.TheparticipantalsoagreesthattheHacktheHood
staff/teachers,BoardofDirectors,itsowners,operators,agentsandemployeesarenotresponsible
forlossordamagetoanyoftheparticipantsproperty.

Theundersignedparticipant,orparentorguardianofparticipant,grantspermissionto
participateinHacktheHoodprogramsat2781TelegraphAvenue,Oakland,CAandrelated
offsiteevents.AsaparticipantIunderstandandagreethatImaybephotographedand/or
videotapedforthepromotionofHacktheHood,andanyartormediaproducedatthecentermay
beincludedinpromotionalmaterialsfortheorganization(i.e.showcasedononlinewebsites).I
amawarethatacolicenseagreementbetweenHacktheHoodandmyselfwillbeenforcedfor
anymediaorartproducedforHacktheHood,unlessotherwiseagreed.Iunderstandthatthereare
risksofphysicalinjurytotheparticipant(s).Consideringallpossiblerisks,onbehalfofthe
participant(s)andmyself,Ivoluntarilywaive,release,discharge,andholdharmlessHackthe
Hood,itsemployees,supervisors,appointedofficials,agents,representativesandvolunteersfrom
allclaimsforallinjuriestoparticipant(s),nomatterhowsevere.Furthermore,Igiveconsentfor
emergencymedicaltreatmenttotheparticipant(s).Thiswaiverdoesnotextendtoanysuchclaim
orliabilitythatiscausedsolelyandexclusivelybythegrossnegligenceoftheHacktheHood,its
employees,supervisors,appointedofficials,agents,representativesandvolunteers.

IauthorizemychildtoenrollintheHacktheHoodprogram.IfIamanadult,Iagreeto
theabovetermsandconditionsofHacktheHood.

Ihaveread,understand,andagreetotheaboveinformationandwaiverofmyrights.

______________________________
Participant

Date:_________________________

______________________________
Parent/Guardian(ifparticipantisaminor)

Date:_________________________

MEDICALINFORMATION

Name:__________________________________

Generalphysicalcondition(circleone):Good
Fair
Poor

Areyoucoveredbyfamilymedical/hospitalinsurance?YesNo

Ifso,indicatecarrierorplanname
Group#
_____

Carrieraddress

Nameofinsured
Relationshiptoyou

SocialsecuritynumberofpolicyholderorinsuranceIDnumber

Allergies:
Listallknown,includingfood,medication,insectstings,hayfever,asthma,etc.

ListBelow
Describereactionandmanagementofthereaction.

Ifyouareallergictobeestings,pleasedescribewhatkindofreactionyouhaveandwhatmedication
youaretakingforit:________________________________________________________________

MedicationsBeingTaken
PleaselistALLmedication(includingoverthecounterornonprescriptiondrugs)takenroutinely.
Bringenoughmedicationtolasttheentireweek.Keepitintheoriginalpackaging/bottlethat
identifiestheprescribingphysician(ifaprescriptiondrug),thenameofthemedication,thedosage,
andthefrequencyofadministration.

ItakeNOmedicationsonaroutinebasisORItakemedicationsasfollows:

Med#1
Dosage

Specifictimestakeneachday

Reasonfortaking

Med#2
Dosage

Specifictimestakeneachday

Attachadditionalpagesformoremedications.

GeneralQuestions
(attachadditionalpagestoexplain"yes"answersbelow)
Have/doyou:

1. Hadanymajorhealthchallenges?
YESNO

2. Everbeendiagnosedwithaheartmurmur?
YESNO

3. Haveachronicorrecurringillness/condition?
YESNO

4. Everhadbackproblems?
YESNO
5. Everhadsurgery?
YESNO

6. Everhadhighbloodpressure?
YESNO
7. Havefrequentheadaches?
YESNO

8. Iffemale,haveanabnormalmenstrualhistory?
YESNO
9. Everpassedoutduringorafterexercise?
YESNO

10. Havediabetes?
YESNO

11. Everhadseizures?
12. Haveasthma?
13. Everhadchestpainduringorafterexercise?
14. Hadmononucleosisinthepast12months?

YESNO
YESNO
YESNO
YESNO

Thistypeoftraining/experiencemaybringupchallengingemotions.Weneedtoknowifyouhaveany
past,chronicorcurrentemotionalproblemsthatmayaffectyourparticipation.Haveyouseena
psychologist,psychiatrist,therapistorothercounselingspecialistinthepasttwoyears?

a)No?Yes?
When
Forhowlong

b)Counseling/treatmentwasrecommendedby

c)Reasonfortreatment?

d)Nameofcurrentormostrecentcounselor
Phone

Address

e)I,
_____________________
willarrangeformycounselor/therapisttoreleaseinformationabout
mydiagnosisandcourseoftreatmentifitisrequestedbythestaffatHacktheHood.

Haveyouundergoneanymajorchangesuchasamove,abirth,adivorceorillness,etc.thatis
impactingyourlifeatthistime,andifso,howareyouadapting?

Usethisspaceorattachadditionalpagestoprovideanyadditionalinformationaboutyour
physical,emotional,ormentalhealthaboutwhichthefacilitatorsshouldbeaware.

HacktheHoodMEDICALWAIVER

ParentPermissiontoProvideNecessaryTreatmentorEmergencyCare(Forparticipantsunder
theageof18)

IherebygivepermissiontothemedicalpersonnelselectedbyHacktheHoodstafftoorderXrays,
routinetests,ortreatmenttoreleaseanyrecordsnecessaryforinsurancepurposesandtoprovideor
arrangenecessaryrelatedtransportationfortheparticipant.IntheeventIcannotbereachedinan
emergency,IherebygivepermissiontothephysicianselectedbytheFacilitationTrainingfacilitatorto
secureandadministertreatment,includinghospitalization,formyson/daughter.Thiscompletedform
may
bephotocopiedfortripsoutoftheFacilitationTraining.

FacilitationTrainingParticipantPermissiontoProvideNecessaryTreatmentorEmergencyCare

IauthorizeanynecessarymedicalactionbyalicensedMedicalDoctorshouldIbeunconscious,require
immediatemedicalcare,andshouldneitheraparent/guardianorotheremergencycontactpersonbe
available.

Alloftheinformationonthismedicalinformationformisconfidentialandwillbesharedonlywiththe

appropriatestaffattheHacktheHoodandthemainoffice.Youthparticipants,staffandtheapplicants
are
allputatriskwhenthisinformationiswithheld.IfyouarriveatHacktheHoodwithapreexisting
condition,injuryorotherhealthproblemnotindicatedonyourhealthformwhichwediscoverbecause
of
itsnegativeimpactonyourexperience,fellowparticipants,staff,ortheHacktheHoodCenter,you
may
berequiredtoleavetheclassorprogramyouareattending.

IagreetoalltheeaboveandIcertifythattheinformationprovidedonthisformistrue,correct
andcompletetothebestofmyknowledge.Myson/daughterhaspermissiontoengageinall
Hack
theHoodactivitiesexceptasnotedabove.

Parent/Guardiansignature(ifunder18)________________________ Date___________________
ParticipantSignature_______________________________________ Date___________________

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