Registration and Waiver for 2024 Japan Trek Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of birth(Required) MM slash DD slash YYYY Passport expiration date(Required) MM slash DD slash YYYY Emergency Contact's Name (not traveling with you)(Required) First Last Emergency Contact's Email(Required) Emergency Contact's Phone(Required)Are you a person with Parkinson's?(Required) Yes No If you are a person with Parkinson's you will need to travel with a buddy who does not have Parkinson's. If you have Parkinson's, please check 'yes' below and add your traveling partner's name.Are you traveling with a partner? (Must check 'yes' if you have Parkinson's.)(Required) Yes No Maybe Partner's Name First Last The partner also needs to fill out a complete registration form.Consent for fundraising(Required) I agree to the fundraising policy.I agree to raise, or donate, a minimum of $2000 that will be equally divided between the Parkinson's Association of San Diego and The Scripps Foundation. The donation to Scripps will be used to help fund an MRI suite for the purpose of facilitating stem cell therapies for Parkinson's disease.RELEASE OF LIABILITY, COVENANT NOT TO SUE, AND RELEASE FOR EMERGENCY CAREGeneral release of liability(Required) I agree to the general release of liabilityI HEREBY UNCONDITIONALLY RELEASE, WAIVE, AND DISCHARGE, and I HEREBY agree to INDEMNIFY and SAVE and HOLD HARMLESS, Sherrie Gould, the Scripps Clinic Medical Group, Jeff Seckendorf and/or Snaproll Films, Scripps Health, The Parkinson’s Association of San Diego, and any persons within these organizations (the Releasees) FROM ALL LIABILITY TO MYSELF, my personal representatives, assigns, heirs, and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR ON ACCOUNT OF INJURY TO MY PERSON OR PROPERTY OR RESULTING IN MY DEATH, NOW AND FOREVER, ARISING OUT OF OR RELATED TO MY PARTICIPATION IN THE POWER OVER PARKINSON'S TREK TO JAPAN TENTATIVELY SCHEDULED FOR MAY 2024 OR ANY RELATED SOCIAL OR TRAINING ACTIVITIES, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HEREBY ACKNOWLEDGE I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it, am aware of its legal consequences, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I understand that this agreement represents the entire agreement between the parties regarding the subject matter hereof and supersedes any prior or contemporaneous agreements. I understand that this agreement may not be orally modified and I am not relying on representations made by anyone other than those set forth in this agreement. I agree to the above paragraph. BY WAY OF MY VOLUNTARY DIGITAL SUBMISSION, I AGREE THAT I HAVE FULLY READ AND UNDERSTAND THIS DOCUMENT IN ITS ENTIRETY. I UNDERSTAND THAT THIS IS A LEGALLY BINDING CONTRACT NOT TO SUE AND AGREE TO BE BOUND BY IT.Consent for medical care(Required) I agree to the medical care and assistance policy.I hereby authorize an emergency service agency, physician or dentist to administer whatever medical care in their professional opinion is necessary for me in the event of fall or injury.Agreement to carry travel insurance(Required) I agree to the travel insurance policy.I agree to purchase and maintain travel insurance for the Power Over Parkinson's trip tentatively scheduled for May 2024. I further agree that the travel insurance will be in force for the total duration of my travel associated with this trip including travel before and after the organized hikes. At a minimum this travel insurance must include medical coverage and evacuation coverage.Photo release(Required) I agree to the photo, video, and audio release.I agree to the use (full or in part and forever) by Releasees of all photographs taken of me and/or video and/or audio recordings made of my voice and/or written extraction, in whole or in part for the purposes of illustration, broadcast, or distribution in any manner. Any and all recordings and photographs become the property of Releasees.Agreement to hold harmless and not to sue.(Required) Agreement to hold harmless and not to sue.I have read and understand the waiver and release. and covenant not to sue and I agree that this agreement shall be construed broadly to provide a release to the maximum extent permissible under applicable law. By agreeing to this document I understand that I may be giving up substantial rights to sue or recover damages.Agreement to print and sign.(Required) I understand I must print and sign this document.I understand for this document to be valid it must be printed and signed by me. Download the PDF document from the confirmation page after submitting this form. A copy will also be emailed to you. The printed form must be returned to Sherrie Gould prior to participation in any traveling, training, or social activity associated with the Komono Kodo trek tentatively scheduled for 2024. PRINT YOUR NAME, SIGN, AND DATE BELOW:
