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___________________