Thank you for your interest in attending UQHS Jambreen Night Walk. Please fill out this survey to get registered.

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* 1. Full Name

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* 2. Email Address

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* 3. Emergency Contact Name and Number

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* 4. Do you have any medical conditions that we should be aware of?

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* 5. Have you read the associated risk assessment for this event?

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* 6. I agree and consent to the following:

In return for being allowed to participate in the UQ Herpetological Society (herinafter "UQHS") event "UQHS Jambreen Night Walk" on January 30 2021 (hereafter referred to as "this event"), including any activities incidental to such participation (hereafter referred to as "Member Activities"), the under-signed Member or Parent/Legal Guardian of Member if Member is under age 18 (hereafter referred to using "I", "me", or "my") releases and agrees not to sue UQHS or its board members from all present and future claims that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or death arising as a result of my participation in the Member Activities wherever, whenever, or however the same may occur, even if caused by their ordinary negligence or otherwise.

I understand that this Agreement is a contract which grants certain rights to and eliminates the liability of UQHS.

I understand that participation in Member Activities involves risks. I have read the risk assessment for this event and am voluntarily participating in the Member Activities with knowledge of the risks involved and I accept all risks of participation.

I understand that this Agreement is intended to be as broad and inclusive as permitted by the laws of the state in which the Member Activities take place and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect.

I also acknowledge that UQHS has not arranged and does not carry any insurance of any kind for my benefit or that of Member (if Member is under age 18), my parents, guardians, trustees, heirs, executors, administrators, successors and assigns. I represent that, to my knowledge, I am in good health and do not suffer any physical impairments that would or should prevent my participation in Member Activities.

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* 7. ELECTRONIC SIGNATURE (type name in box below)
(Minors, if the participant is under the age of 18, Parent’s Signature or legal guardian’s signature)

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* 8. Confirm Current Date

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