Participant authorizes Katia & Company, Inc, and their respective affiliates, agents, owners, principals, officers, volunteers, organizers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as K & Co), to be treated as Participant would be treated with respect to Participant’s rights regarding the use and disclosure of my individually identifiable health information and other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIP AA"), 42 U.S.C. 1320d and 45 C.F.R. 160-164.
This authority given to K & Co shall supersede any prior agreement that Participant may have made with health-care providers to restrict access to or disclosure of individually identifiable health information. The individually identifiable health information and other medical records given, disclosed, or released to any named agent may be subject to re-disclosure by a named agent and may no longer be protected by HIPAA. The authority given to K & Co herein shall expire one year from execution, unless earlier revoked by Participant in writing and delivered to K & Co and Participant’s health-care providers. There are no exceptions to Participant’s right to revoke this HIP AA Release.
In consideration of the services of K & Co Participant does hereby release, indemnify, and discharge K & Co, on behalf of Participant, his/her relatives, heirs, assigns, personal representative and estate as follows.
1. Participant acknowledges that participation in Camp Activities entails known and unanticipated risks, which could result in physical or emotional injury, paralysis, death of Participant or others, or damage to property of Participant or others. Participant understands that such risks simply cannot be eliminated without jeopardizing the essential qualities of the Camp Activities.
Camp Activities are offered on the “challenge by choice” principle. Participation is subject entirely to the desire and discretion of Participant. At any time, Participant and/or Participant’s group are free to decline or withdraw from participation in any activity. The risks of participation include, among other things, the potential for: slips, falls or falling; pinches, scrapes, twists and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe, even life threatening, hazards. During an activity or travel in between there may be contact with plants, animals or insects that could create hazards such as stings, allergies, and associated diseases.
Furthermore, Participant acknowledges that staff and facilitators have difficult jobs to perform. They seek safety, but they are not infallible.
2. Participant expressly agrees to, promises to and hereby does accept and assume all of the risks existing in Camp Activities. Participation is purely voluntary, and Participant’s election to participate is in spite of all risks.
3. Participant does hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Katia and Company from any and all claims, demands, or causes of action, which are in any way connected with Participant’s participation in Camp Activities or use of K & Co equipment or facilities, including but not limited to any such claims which allege negligent acts or omissions of K & Co
4. Should K & C0 or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this agreement Participant agrees to indemnify and hold them harmless for all such fees and costs.
5. Participant certifies that he/she has adequate insurance to cover any injury or damage he/she may cause or suffer while participating, or else Participant shall bear the cost of such injury or damage directly. Participant further certifies that he/she is willing to and hereby does assume the risk of any medical or physical condition he/she may have.
6.  Participant agrees that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
7. Participant consents for all purposes to the sale, reproduction and/or use of photographs of the Participant (with or without the use of the Participant’s name), by K & Co and by the respective nominees and designees of K & Co in all forms and media and in all manners, including but not limited to trade, display, advertising, editorial, art and exhibition. In giving this consent Participant releases K & Co, and the respective nominees and designees from liability for any violation of any personal and/or proprietary right Participant may have in connection with such sale, reproduction or use.
By signing this document, Participant acknowledges that if anyone is hurt or any property damaged during Participant’s participation in K & Co activities, Participant may be found by a court of law to have waived his/her right to maintain a lawsuit against K & Co on the basis of any claim from which he/she has released K & Co herein.
Participant has had sufficient opportunity to read this entire document. Participant has read and understood it and agrees to be bound by its terms.

If participant is accepted, you will receive an invoice to complete registration .