MANATEE SCHOOL FOR THE ARTS

GERMAN AMERICAN PARTNERSHIP PROGRAM PERMISSION FORM

Participant Name : ______

Parent/Guardian Name: ______

INTRODUCTION

This agreement governs the above-named Participant'sparticipation in the German American Partnership Program ("the Program") a noncommercial, educational opportunity co-sponsored by the Manatee School for the Arts ("MSFTA") and Werner-Von-Siemens-Gymansium, Weissenburg, Bayern, Germany, including all field trips and excursions connected with the Program. The Program will take place from June 15, 2017, through June 30, 2017.The following individuals will serve as the Program chaperone(s): Victoria Kazanski ("the Chaperones").

PROGRAM CHANGES:

MSFTA reserves the right to make changes to the Program for the safety, comfort and convenience of participants, whenever, in the sole judgment of the Chaperones, such changes are deemed necessary.

Student initial: ______Parent/Guardian initial: ______

WAIVER OF LIABILITY:

In exchange for being allowed to participate in the Program, I, and my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following:

1. Voluntary Participation. I understand and confirm that my participation in the Program isvoluntary. By participating in this program, I certify that I am physically and emotionally capable of full participation.

2. Identification of Risks. I understand that my participation in the Program may involve risk of injury and loss, both to person and to property. I also understand that the risk of injury may include the possibility of permanent disability and death. I understand that this Waiver and Release of Liability is intended to address all of the risks of any kind associated with my participation in any aspect of the Program, or with the time I am involved in the Program, including, particularly, such risks created by actions, inactions, or negligence on the part of MSFTA or its directors, officers,employees, agents, volunteers, successors, or assigns, including but not limited, to riskscreated by the following: (a) the use and condition of various modes of transportation,premises, facilities, and equipment; (b) the lack or inadequacy of policies, rules, orregulations of the Program; (c) the failure of MSFTA to foresee or to protect me fromactions, inactions, negligence, recklessness, or intentional or criminal misconduct ofpersons, other than those employed byMSFTA; (d) the inadequacy or unavailability ofmedical facilities or treatment; (e) the lack or inadequacy of supervision; (f) forces of nature; (g) labor strikes, acts or omissions of foreign governments, terrorism, war or insurrection; (h) loss of passport, airline or train tickets or other documents or personal belongings; or (i) damage to luggage or other personal belongings.

3. Assumption of Risk. I assume all risks, known and unknown, foreseeable andunforeseeable, in any way connected with my participation in the Program. I acceptpersonal responsibility for any liability, injury, loss, or damage in any way connected with my participation in the Program.

4. Release.I release the Chaperones and MSFTA and its directors, officers, employees, agents,volunteers, successors, and assigns from any and all liability and waive any and allclaims for injury, loss, or damage, including but not limited to attorneys’ fees ordamages, losses or injuries encountered in connection with transportation, food, lodging, medical concerns (physical and emotional), entertainment, photographs, and physical or emotional injury of any kind, whether or not caused in whole or part by thenegligence or other misconduct of the Chaperones, MSFTA or its directors, officers, employees, agents, volunteers, successors, and assigns.

5. Indemnification. I agree to indemnify and to hold harmless (in other words, to reimburseand to be responsible for) the Chaperones, MSFTA and its directors, officers, employees, agents,volunteers, successors, and assigns from all claims for any liability, injury, loss, damages,or expense, including attorneys’ fees (including the cost of defending any Claim I mightmake, or that might be made on my behalf, that is released or waived by this instrument),in any way connected with or arising out of my participation in the Program, whether ornot caused in whole or in part by the negligence or other misconduct the Chaperones, MSFTA or its directors, officers, employees, agents, volunteers, successors, and assigns.

6. Binding Effect. This instrument shall be binding upon my relatives, personalrepresentatives, heirs, beneficiaries, next of kin, or assigns and shall inure to the benefitof MSFTA and its successors and assigns.

7. Consent to Medical Treatment. I authorize MSFTA to provide to me, through medicalpersonnel of its choice, customary medical assistance, transportation, and emergencymedical services, including the administration of an anesthetic, surgery or dental treatment. This consent does not impose a duty upon MSFTA to provide suchassistance, transportation, or services.I acknowledge that, in the event that I become sick or injured, I will bear all financial responsibility for medical costs and costs for transportation to the United States from the Program site, should that become necessary.

8. Agreement to Arbitrate. MSFTA and I agree to use confidential, binding arbitration, instead of going to court for any claims that arise out of my participation in the Program. In any arbitration, the rules of the American Arbitration Association will apply.

9. Severability. If any term or provision of this instrument or the application thereof to anyperson or circumstances shall to any extent or for any reason be invalid or unenforceable,the remainder of this instrument and the application of such term or provision to personsor circumstances other than those as to which it is held invalid or unenforceable shallnot be affected thereby, and each term and provision of the instrument shall be valid andenforced to the fullest extent permitted by law.

10. Applicable Law. Because MSFTA is headquartered in the State ofFlorida, and in order to provide certainty in the law to be applied to the construction ofthis instrument, this instrument shall be governed, construed, and enforced in accordancewith the law of the State of Florida.

Student initial: ______Parent/Guardian initial: ______

PERSONAL CONDUCT AGREEMENT:

MSFTA has the authority to establish rules of conduct during the entirety of the Program, including free time. In exchange for being allowed to participate in the Program, I, and my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following:

  1. Attend all Program activities as specified by the Chaperones. In the event the Participant becomes detached from the Program, or fails to meet a departure plane, train or bus, he or she bears all financial responsibility for costs attendant to contacting the Chaperones and/or reaching the Program site.
  1. Conduct myself in a manner that will be a credit to MSFTA, my family, and myself by displaying mature, courteous and thoughtful behavior at all times.
  1. Obey all rules and safety precautions established by the Chaperones during traveland other Program activities.
  1. Report to the Chaperones and my host familyany absence from my host family for more than one day.
  1. Abide by the Alcohol Use Responsibility Agreement. Excessive alcohol use will be considered unacceptable behavior and will result in immediate notification of parents and disciplinary action, including the possible return to the United States at the Participant's expense, or the expense of his or her parents or legal guardians.
  1. Refrain from any driving of any vehicle while in Germany. Any driving will be considered illegal operation of a motor vehicle and will be reported to the local authorities.
  1. Refrain from possession or use of drugs or other illegal substances. Use or possession of drugs or other illegal substances will result in the participant's immediate return to the United States at his or her expense, or the expense of his or her parents or legal guardians.
  1. Obey all laws of the jurisdiction where Program activities take place. In the case of arrest, the student becomes the total responsibility of his or her parents or legal guardians.

MSFTA reserves the right to refuse to accept or to retain any person as a Participant in the Program, either before departure or during the course of the exchange visit. Should MSFTA decide that a Participant must be separated from the Program because of violation of stated rules, for disruptive behavior, or for any conduct that might bring the program into disrepute or its Participants or MSFTA into legal jeopardy, that decision will be final. Participants dismissed from the Program will remain responsible for all program costs incurred on their behalf and for the cost of their transportation to the United States from the Program site.

Student initial: ______Parent/Guardian initial: ______

Alcohol Use Responsibility Consent and Agreement:

The sampling of wine and beer is regarded by many as an educational and cultural part of a European experience. The Participant's parents or guardian may grant the Participant permission to partake in the occasional and limited use of wine and beer in accordance with the following regulations:

  1. The use of alcohol is granted ONLY upon parental/guardian consent. All student participants, regardless of age, MUST have parental/guardian consent.
  1. The experience is limited STRICTLY to wine and beer and limited to ONE glass per occasion, at the discretion of the chaperones.
  1. The use of such beverages shall be only in the presence of a chaperone or the host
  1. parents during the family stay.
  1. The chaperones reserve the right to withdraw the privilege if it is abused by the student participant.
  1. It is understood that the abuse of alcohol will result in disciplinary action, including the possible return to the United States at the expense of the participant and his or her parents/legal guardians.

I ___ DO ____ DO NOT [check one] grant ______[student name] permission to partake in the limited use of wine and beer, and I am in full agreement with the regulations and procedures as outlined above.

______

Parent/Guardian SignatureDate

I will comply with my parent/legal guardian's wishes concerning alcohol consumption during the Program, as noted above. If my parent/legal guardian has consented to alcohol consumption, I accept the responsibility of limited use of wine and beer during the GAPP exchange in Germany. I agree to the regulations and procedures outlined above.

______

Student SignatureDate

PROMOTIONAL RELEASE:

In exchange for being allowed to participate in the Program, I, and my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following

I grant MSFTA permission to photograph and/or video me for possible appearance and inclusion in any MSFTA or Program publications or web sites, including the GAPP exchange web site, MSFTA web site, and/or the GAPP Facebook page.

I release MSFTA of any claims, demands, damages, actions and causes of action arising from or connected in any way with the use of photographs and/or videos.

I understand that I will receive no compensation for my participation and that all photography and videos resulting from my participation in the Program will become the sole property of MSFTA.

Student initial: ______Parent/Guardian initial: ______

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SIGNATURES ARE REQUIRED ON THE NEXT PAGE – AND PARENT/GUARDIAN SIGNATURE MUST BE NOTARIZED

I have completely read and fully understand the foregoing Waiver of Liability, including the provisions governing Consent to Medical Treatment and Agreement to Arbitrate, the Personal Conduct Agreement, the Alcohol Use Responsibility Form and the Promotional Releaseand agree to be bound thereby.

______

Student SignatureDate

I, the parent or legal guardian of the above student, have completely read and fully understand the foregoing Waiver of Liability, including the provisions governing Consent to Medical Treatment and Agreement to Arbitrate, the Personal Conduct Agreement, the Alcohol Use Responsibility Form and the Promotional Releaseand agree to be bound thereby, and to cause the above student to comply therewith.

______

Parent SignatureDate

STATE OF FLORIDA

COUNTY OF ______

The foregoing instrument was acknowledged before me by ______, who is personally known to me, or produced identification ______.

WITNESS my hand and official seal in the City of ______,

State and County aforesaid, this _____ day of ______, 2015.

______

NOTARY PUBLIC

Print Name:

ADDITIONAL INFORMATION

Parent/Guardian Name: ______

Home Phone: ______Work Phone: ______Cell phone: ______

Insurance Company: ______Policy Number: ______

Insurance Phone: ______Insurance Address: ______

Participant Allergies: ______

Current Medications: ______

Emergency Contact: ______Phone: ______

Relationship: ______

INSURANCE, TRANSPORTATION, and PERMISSION TO TREAT

I have attached a photocopy of my child’s health insurance card to this packet.

Signature______Date:______

GAPP chaperones and licensed medical personnel have my permission to medically treat my child, should the need arise. In addition, my child’s host parents in Germany have my permission to authorize medical treatment in the event of an emergency.

Signature______Date:______

Please list any health or other information that we should be aware of, including allergies, regular medications, and directions for administering.

______

______

______

______

______

Signature______Date:______

STATE OF FLORIDA

COUNTY OF ______

The foregoing instrument was acknowledged before me by ______, who is personally known to me, or produced identification ______.

WITNESS my hand and official seal in the City of ______,

State and County aforesaid, this _____ day of ______, 2015.

______

NOTARY PUBLIC

Print Name:

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