This form is to authorize Round Top Festival Institute, 248 Jaster Road, Round Top, TX 78954, their agents, representatives and employees [hereinafter "Institute"] to obtain emergency medical assistance and to provide transportation, and to release the Institute from liability for injuries to myself while on the Institute premises or otherwise in the care of the Institute staff members.
I hereby authorize any agent, representative or employee of the Institute to take me to
Dr. ________________________ (specify name or indicate “ANY”)
Phone ______________________
Address _____________________________________________
or to _____________________________________________ Hospital
where medication or medical procedures they may deem necessary for me will be administered. The undersigned further agrees to be financially responsible for all such medical services, including the cost of defense and enforcement of this indemnity agreement.
I further understand and agree that the Institute, its agents, representatives or employees may administer simple first aid in the event of minor injuries, and family members or doctors will be called when in the discretion of the Institute personnel, it is deemed necessary.
I/we represent that I am fully responsible for my care and wellbeing. I agree that the Institute shall not be liable for any damages, claims or compensation of whatever nature (including liabilities for negligence, strict liability, or otherwise) that may arise to me of for my benefit while I am on the premises of the Institute or otherwise in the care of the Institute personnel, including such injuries sustained while I am being transported to programs of the Institute.
I/we have read the foregoing and agree with it in all respects.
Signed on _________________________(Month/Day/Year)
Signature _______________________________________
