Departure Date: 7 22 May 2017 ALL HANDS ON EVEREST, ISLAND PEAK REGISTRATION Personal Information Name Date of Birth Nationality Group/Affiliation Contact Information Email Phone Home Address City State Zip Code/Province Country Professional Information Employer Title Location Emergency Contact Information Contact Name Relationship Contact s Phone Contact s Email Medical Information Blood Type Please List Any Medical Conditions and/or Allergies Please List Dietary Restrictions (e.g., Vegetarian) Yes, All Hands may send a press release about my volunteer experience to newspapers. Publicity helps All Hands spread the word about our efforts.
HOLD HARMLESS AGREEMENT I acknowledge that I have been informed by the terms of this agreement that my participation in a trek in Nepal (the Challenge ) organized by All Hands Volunteers, Incorporated, a non-stock non-profit organization incorporated in Nepal ( All Hands ), involves physical challenges that are potentially hazardous and/or dangerous. I acknowledge that my participation in the Challenge may expose me to illness, injury, emotional trauma or illness, disability and/or death. I understand that I may be traveling and living in dangerous and unhealthy circumstances with limited access to medical care. I also acknowledge that I may be exposed to dangerous equipment and/or dangerous conditions, which may cause injuries and/or death. I acknowledge that the All Hands employees and volunteers and other participants with whom I will be traveling and living are, by the nature of the Challenge, subject to errors in judgments and decisions. Among the possible mistakes in judgments and decisions are: my physical and emotional ability to handle the tasks and conditions existing during the term of my participation in the Challenge; a failure to correctly assess any injury or physical or mental health condition I may have at the time of my participation in the Challenge or sustained during the period of my participation in the Challenge; and my experience or expertise in trekking or my assigned tasks. I acknowledge and affirm that I have had the opportunity to ask any questions I may have of All Hands personnel prior to my departure for the Challenge and prior to the commencement of my participation in the Challenge. I also acknowledge that despite any answers I have received from my inquiries, the conditions and circumstances of my participation in the Challenge may change to meet the conditions of traveling to, from, and within Nepal and living in the Nepal. If at any time I conclude that I am physically or emotionally incapable of performing a task or enduring the conditions existing during my participation in the Challenge, I understand that it is my sole responsibility to inform All Hands personnel that I cannot or will not perform an assigned task or that I cannot or will not continue to endure the conditions of my participation in the Challenge. Should I elect to continue to participate in the Challenge after informing All Hands personnel or volunteers of my reservations about continuing to participate, I fully acknowledge that the decision to do so is my own, free from pressure or duress by any person. I understand that I am free to end my participation in the Challenge at any time, but that I will be responsible for any additional travel costs and other expenses incurred by me as a result of leaving the Challenge early. I agree that my decision to participate in the Challenge is my certification that I am physically and emotionally capable of participating in the Challenge despite any prior representations I may have made regarding my physical and/or emotional health. I hereby agree, on behalf of myself and my children, heirs, executors, administrators and assigns, to the fullest extent allowed by applicable law, to release, indemnify and defend All Hands and any and all of its affiliates (including All Hands Volunteers, Inc., a Massachusetts, U.S.A. non-profit corporation), volunteers, personnel, board members, contractors, partners, donors and associates (each an All Hands Indemnity ) with respect to all claims, liabilities, losses, suits or expenses, including all litigation costs and attorney s fees, brought by anyone, including me, in connection with my participation in the Challenge. By this agreement I agree to waive all claims, whether legal or equitable, for losses I may claim to be caused, in whole or in part, by the negligence or other wrongdoing of any All Hands Indemnity. I authorize All Hands to copyright, publish, use, sell or assign any and all photographic portraits or pictures, television spots, movie films, videotapes and/or sound recordings or any part thereof that may have been taken of me during my participation in the Challenge. I hereby waive any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied. I authorize All Hands to seek and obtain medical care for me should its personnel deem it necessary to do so. I also authorize All Hands to seek and obtain my evacuation from the Challenge route. In so doing, I agree to hold harmless any and all persons who seek or obtain my evacuation and/or medical care. I also agree to assume full responsibility for the cost of all medical services and/or evacuation. I agree that this agreement shall be governed by the laws of the Commonwealth of Massachusetts, U.S.A., without regard to conflicts of laws principles. Should any portion of this agreement be determined to be unenforceable, the remaining portions of the agreement shall remain in full force and effect without modification. I have read this document, or in the event I am unable to read this agreement by reason of language and/or understanding, I have independently undertaken to have it read to me or translated for me, and I acknowledge that I have voluntarily signed it, and that no oral or written representations, statements, or inducements apart from the terms of this agreement have been made to me in signing this agreement. I further agree that no prior or contemporaneous oral or written statement may be used by me to modify the terms of this agreement nor may this agreement be modified in any respect following the date of my signature except by way of a written modification agreement with All Hands. I understand that this agreement is subject to All Hands privacy policy, which assures me that All Hands will not share my personal information with anyone outside the organization without my permission. Additionally, I have been assured that all information regarding me, whether collected online or in person, is collected via secure channels and stored in All Hands secure databases and facilities subject to All Hands privacy policy. Participant Signature Date
FINANCIAL COMMITMENT FORM (Please place Initial in the Spots Provided) I agree that by signing this form I am committed to the All Hands on Everest, Island Peak Trek taking place from May 7, 2017 to May 22, 2017. By signing this form, I understand that I am aware of all the financial requirements. I fully understand that the following payments will be charged to my credit card on the following dates. These costs can be partially or wholly offset by my personal fundraising efforts based upon my personal efforts and communications with my family and friends. A $300 deposit will be charged to my credit card upon registration is non-refundable, even in the event that I have to cancel my reservation. This money will serve as a down payment to the outfitter, Explore Himalaya. $2125 on April 21, 2017 that will cover the balance of the cost of the trek to Explore Himalaya. The $3,000 fundraising requirement by April 21 st, 2017. All of these funds (100%) will go directly to help the people of Nepal recover from the earthquake. This payment can be partially, or wholly, offset by personal fundraising efforts by creating and sharing your personal fundraising page. I fully understand what amenities are included and what amenities are not included in the overall price of the trek. I understand that the cost of the trek does not include international airfare, visa costs, travel insurance, or any extra expenses. I fully understand that the $3,000 fundraising requirement is my own personal responsibility. I understand that I will owe any remaining balances if the $3,000 minimum is not met. I hereby authorize All Hands Volunteers to initiate an automatic deduction from my credit card if the remaining balance for the $3,000 fundraising minimum is higher than $0.01 on or after April 21 st, 2017. I understand that I owe a total of $5,425.00 with the cost of the trek and the fundraising requirement combined. All payments are expected to be paid on time to All Hands Volunteers. I agree to abide by the dates listed in the obligation and commitment form. If any of these financial commitments are not met, I agree to be subject to any fees or costs associated with the trek and/or fundraising requirement to be charged to my account. Your signature on this form signifies that you will fulfill all the financial commitments as initialed above. Participant Signature Date
CREDIT CARD PAYMENT AUTHORIZATION FORM Complete and sign to authorize All Hands Volunteers to make the following debits to the credit card listed below. 1. Non Refundable Deposit $300 due at time of registration. This will be applied to the cost of the trek. 2. $2125 on April 21 st 2017 (for a total of $2425 to cover the costs of the outfitter (Explore Himalaya) 3. $3,000 on April 21 st, 2017. This is your minimum fundraising requirement. 100% of these funds will go directly to help the people of Nepal recover from the earthquake. 4. This payment can be partially or wholly offset by personal fundraising efforts by creating and sharing your personal fundraising page. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for the three transactions listed above only, and does not provide authorization for any additional unrelated debits or credits to your account. Please complete the information below: I (full name) authorize All Hands Volunteers to charge my credit card account indicated below for on or after (Amount) (Date). This payment is for (description of goods/services). Billing Address Phone# City, State, Zip Email Account Type: Visa MasterCard AMEX Discover Cardholder Name Account Number Expiration Date CSV (Credit Card Security) Number
SIGNATURE DATE I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.