Name *

First Name

Last Name

Date

MM

DD

YYYY

Cell Phone *

(###)

###

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Media Release *

I voluntarily give "The Vertimax Room" (The Road College Prep Academy) and it’s partners permission to use photos, participant’s name and/or testimony of the participant listed above for public or media resources including newsletters, speaking engagements, appeals for sponsorships, news and video releases, etc. for the purpose of educating the public about "The Vertimax Room" (The Road College Prep Academy) and for the solicitation of new clients. The Release will be valid for 3 years. The Participant and/or Parent/Guardian (if participant is a minor) may request in writing to withdraw permission at any time.

Release Form *

I acknowledge that participation in the The Road College Prep program involves risk to the participant , and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activities at the Road College Prep Academy, the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in The Road training activities. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during activities as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activities, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association. I authorize The Road Prep Academy staff/volunteers to transport via vehicle or ambulance the participant to the nearest hospital. I also authorize hospital staff to provide any and all necessary emergency medical treatment.