Visual / Audio Image Release Form

I grant permission to The Gatherer Institute, its employees and agents, to take and use visual/audio images of me and/or my children) . Visual / audio images are any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. The images may be used in any manner or media without notifying me, such as The Gatherer Institute-sponsored Web sites, publication, promotions, broadcasts, advertisements, posters and theater slides, as well as for non-Gatherer Institute uses. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them. I release The Gatherer Institute and its employees and agents, including any firm authorized to publish and/ or distribute a finished product containing the images, from any claims, damages or liability which I may ever have in connection with the taking of use of the images or printed material used with the images.

Printed name of subject:

Signature of subject:

Parent or guardian if under 18 years of age:

Telephone or e-mail address:

Address (optional):

Date:

Major:

Year in School:

Project: NJ Walkabout 2009

Gatherer Institute/Videographer Contact:

Code of Conduct

1. I will attend scheduled meetings and inform the team if I am unable to attend.

2. I will accomplish my tasks within the deadlines.

3. I will never require of my people something that I am unwilling to do myself.

4. I understand and submit to the established hierarchy and to the expertise of others.

5. I will work with my team to solve problems.

6. I understand and abide by the Laws of The Caretaker- I will only take life to ensure my own life, and the life of those in my care. I will make every effort to protect that life which will produce the strongest future for its own.

7. I will hunt and gather, eat and drink, protect and prevent reflecting gratitude for the gift of creation.

8. I will never disdain the faith of others or case them to feel uncomfortable when worshipping,

practicing, traditions expressing beliefs.

9. I will not ridicule or mock anyone involved.

10. I will not consume alcoholic beverages, posses any illegal drug, or knowingly break any law in my activities with the Institute.

11. I will not steal, cheat, lie, or fight. I will observe the traditions of argument and

discipline set down in my training.

12. I will bring my objections through the proper channels, following the proper chain of command. If I believe anyone is guilty of a wrongdoing, I will express objections in an appropriate manner, without foul language.

13. I will not hold the Gatherer Institute

liable for loss or breakage of my personal items.

14. I will follow safety rules.

15. I will not react to hecklers or protesters except as prescribed by my training.

16 I will attempt to resolve problems within my team before I bring them up the chain of command.

17 I Will safeguard the privacy of those in my charge.

I have read the Code of Conduct and agree to abide by the conditions as a participant in Gatherer Institute activities. I understand that if I break this code, I am subject to removal from activities.

Signed__________________________________________________________

I understand that my child is subject to this code of conduct, and that violation of this code could lead to his/her dismissal.

Signed__________________________________________________________

Name:	Birth Date:	Sex:	Age:
First Initial Last
Parent or Guardian Name:	Phone #:	Cell	Work
Home Address:
If not available in an emergency, contact
If not available in an emergency, contact:
If not available in an emergency, contact:

Health History: (check -- giving approximate dates where indicated)

Name of Physician:

Phone:

Date of last physical examination:

Do you carry family medical/hospital insurance?

If so, indicate:

Carrier:

Policy or group #:

Suggestions or health related information for walkabout personnel:

For females:

Has this person menstruated:

If not, has she been told about it

If so, is her menstrual history normal?

Special considerations

IMPORTANT -- This box must be completed for attendance

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.

Emergency Authorization: I hereby give permission to the medical personnel selected by the director to order x-rays, routine tests and treatment for me or my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician to hospitalize, secure proper treatment for, and to order injections or anesthesia and/or surgery for me/or my child as named above

Signature of parent or guardian:

Date:

I understand and agree to abide with the restrictions placed on my activities. Name of Minor:

Conditions:

Frequent ear infections

Heart defect/disease

Convulsions

Bleeding/Clotting

Diabetes

Asthma

Other:

Allergies: Penicillin

Insect sting

Poison ivy

Hay fever

Other Allergies:

Diseases: Measles

Chicken pox

Mononucleosis

German Measles

Mumps

Prescription drugs taken on a regular basis:

Operations or serious injuries (dates):

HOLD HARMLESS AGREEMENT

Between the Gatherer Institute and

Name of NJ Walkabout 2009 Participant ____________________________________________

Tel #____________________________________

Street Address (Not P.O. Box) ___________________________________________________________________________

City_____________________________________________________ State___________ Zip __________________________

In exchange for participating in the NJ walkabout 2009, sponsored by the Gatherer Institute, a non-profit corporation, the undersigned agrees to indemnify, and hold the Gatherer Institute and its officers, agents and employees harmless from any and all liability, claims, costs and attorney's fees arising out of the undersigned’s participation in the NJ Walkabout 2009, specifically including claims for negligence on the part of the Gatherer Institute and its staff, including volunteers, and including claims for personal injury use of any property, public or private which serves as a host for NJ Walkabout 2009. The undersigned also agrees to indemnify the Gatherer Institute and its officers, agents and employees from any losses or damages resulting from the acts or omissions from any guest, participant, visitor or other person attending the event herein referred to.

Signed this ____________ day of _______________________ 2009

as the binding act in deed of

____________________________________________________________

Name of Participant

____________________________________________________________

Authorized Signature on behalf of Participant under the age of 18.

____________________________________________________________

Authorized Signature on behalf of Gatherer Institute

Packing list

Required Packing List-

For the walk

6 white T-shirts bring ASAP!!

15 pairs of non-cotton socks

Wide-rimmed hat

Case of water

24 breakfast bars, or portable breakfast.

Other Required Items

Sleep:

Sleeping bag.

Clothing

7 Pairs appropriate underwear (no thongs)

7 Bras (Females)

4 changes of clothes to change into after walk.

1 Pair broken in sneakers-

Backup sneakers

1 Modest swimsuit

Conservative sleepwear

Ticks

5 small pillboxes and cotton swabs.

1 small, hand-held mirror

1 roll of masking tape

1 Lint roller/brush

Sharpie- thinnest size.

For the walk

Other Required Items

Suggested Items

Hygiene Items

Additional Items