Please fill out the application and submit your payment for the 2024 Sagamore Summit held June 28-30 at Butler University.
Information about the student
Sagamore Leadership Initiative, Inc. Waiver & Release of Liability & Permission for Treatment (to be completed by parent or legal guardian):
Medical and Liability Release (please read carefully. This must be signed and dated by both student and parent/guardian): I, the legal custodial parent or guardian of signed student below, who desires to voluntarily participate in the Sagamore Summit, assume all responsibility for any accidents or other mishaps, including but not limited to, serious bodily injury, permanent disability, and/or death, with respect to my child. I hereby waive my right and child’s right to any claim, cause of action, and/or the right to file a lawsuit, and further release Sagamore Leadership Initiative, Inc., and the directors, officers, sponsors, employees, agents, and volunteers of said entity from any and all responsibility or liability of any nature whatsoever for any loss or damage to my child’s property or person, including personal injury and/or death sustained at the Sagamore Summit. This instrument shall be binding upon the relatives, personal representatives, heirs, beneficiaries, next of kin or assigns of the above-named child and shall inure to the benefit of the organization named as well as its directors, officers, sponsors, employees, agents, volunteers, successors and assigns. I have carefully read this Waiver & Release of Liability & Permission for Treatment. By my signature, I am declaring that I understand, and accept all of its provisions, and understand that I am giving away substantial legal rights for both myself and my child to pursue any legal action and have the appropriate authority to execute this Waiver & Release. I also give permission to those in authority of Sagamore Leadership Initiative, Inc. at the Sagamore Summit to order x-rays, routine tests and treatment for my child if I cannot be reached in an emergency. I further give permission to hospitalize, secure treatment, and order injections, anesthesia, or surgery for my child named above.
I, the undersigned, do hereby consent and agree that Sagamore Leadership Initiative, Inc. (SLI), its employees, or agents, have the right to take photographs, videotape, or digital recordings of my child and to use these in any and all media, now or hereafter known, and exclusively for the purpose of promoting or making known programs, projects, services, events or other SLI activities. I further consent that his or her name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to Sagamore Leadership Initiative, Inc., its agents, and employees, all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.
