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LCSTL Travel Waiver & Emergency Information Form

Trip: Connect Ed trip to Atlanta, Georgia
Dates: Sunday, November 8 – Tuesday, November 10, 2026
Trip Leaders:
Paco Lee (314.778.0488 / paco@weform.life)
Yeabsera Amare (301.613.3185 / yeabsera@weform.life)

Participant Information

Full legal name

Date of birth

Phone number

Email address

Home address

Maryville student ID number (optional)

Emergency Contacts

Primary emergency contact name

Primary contact relationship

Primary contact phone number

Secondary emergency contact name (optional)

Secondary contact relationship (optional)

Secondary contact phone number (optional)

Health Insurance

Do you have health insurance?

Yes

Medical Information

Allergies

Medications I will bring

Medical conditions trip leaders should know about

Dietary needs

Primary physician name

Primary physician phone number

Assumption of Risk

Travel and trip activities involve risks including vehicle or air travel, accidents, illness, injury, theft or loss of property, weather, and the actions of others. By submitting this form, you acknowledge that you voluntarily accept these risks.

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I have read and agree.

Release and Waiver of Liability

I release and agree not to sue Life Creative STL, BOS Media Group LLC, and their owners, staff, volunteers, partners, and agents for any injury, illness, loss, or damage from participation, except in cases of gross negligence or willful misconduct. Life Creative STL is not responsible for lost or damaged personal property.

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I have read and agree.

Medical Treatment Authorization

I authorize the trip leader to seek emergency medical treatment if I am unable to make decisions for myself and to share this form's information with medical providers. I understand I am responsible for any costs not covered by insurance.

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I have read and agree.

Code of Conduct

Participants are expected to follow the itinerary and trip leaders' instructions, treat everyone with respect, follow all laws (no alcohol for anyone under 21), not leave the group without telling a trip leader, respect curfews and lodging rules, and represent Life Creative STL and Maryville University well. Serious violations may result in being sent home at the participant's own expense.

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I have read and agree.

Photo and Media Release

I give Life Creative STL permission to use photos, video, and audio of me from the trip for educational, promotional, and social media purposes without compensation or I do not give permission.

I give permission.

I do not give permission.

Acknowledgment

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I confirm I am at least 18 years old, the information I provided is accurate, and I sign this form voluntarily.

Signature

Please sign here