Name of Sponsor : _______________ Rank of Sponsor : __________________

Department / Squadron: ______________ FFDC Representative: ________________

NOTE: This is a general release of liability, which, when executed, becomes a binding document releasing the United States Government, the Department of Defense, the Department of the Navy, Commander Seventh Fleet, Commander Carrier Task Force 70, Carrier Air Wing Five, Destroyer Squadron Fifteen, USS George Washington (CVN 73), and all officers, crew, employees, agents, and authorized representative of any of these agencies, entities or units, from any and all liability whatsoever arising from injuries to you and/or your minor child or ward, as well as damage to or loss of property, while embarked on board USS George Washington (CVN 73). Before signing this release, you should read this document carefully and consider all possible implications and associated risks prior to signing it. If you wish to give permission for your minor child or ward to participate in the Friends and Family Day Cruise, you must also complete the embark Authorization form appended hereto.

I and/or my child(ren) or ward(s), listed below, am/are/is embarking as a passenger on board USS George Washington (CVN 73) in the month of August, 2011. The purpose of this embarkation is voluntary participation in the event commonly known as the “Friends and Family Day Cruise.” I hereby confirm that participation in this event is strictly voluntary and done knowingly, intentionally, and of free will, having considered all of the attendant risks associated with the Friends and Family Day Cruise, of which I have been fully informed. I understand that because USS George Washington (CVN 73) is an industrial environment, there is a heightened risk of injury on board, especially while the ship is at sea. I specifically and expressly request permission for me and/or my child or ward to embark on board USS George Washington (CVN 73), for the Friends and Family Day Cruise. In consideration of the permissions extended to me and/or my child or ward to participate in the Friends and Family Day Cruise, I hereby knowingly, intentionally, voluntarily and forever release the United States Government, the Department of Defense, the Department of the Navy, Commander Seventh Fleet, Commander Carrier Task Force 70, Carrier Air Wing Five, Destroyer Squadron Fifteen, USS George Washington (CVN 73), and all officers, crew, employees, agents, and authorized representative of any of these agencies, entities or units, from any and all claims, actions or causes of action arising out of death, injury, and/or any damage, destruction, or loss of any property belonging to me and/or my child or ward. This knowing and intentional release covers any cause of action or claim whatsoever arising during said embarkation or continuances thereof, as well as all other operations incident thereto. This release and discharge is binding upon my heirs, agents, executors, administrators, and personal representatives.

I hereby grant my express, voluntary, and knowing consent to the rendering of all emergency medical or dental treatment that may, in the professional judgment of the Medical Officer or Dental Officer, become necessary while embarked aboard the aircraft carrier. Emergency care is the only type of care authorized. Guests with chronic or incipient medical problems should be aware of the limitations of extended care available afloat. Transportation to a definitive care facility may be required as an adjunct to authorized emergency medical or dental care. Personnel receiving medical or dental care who are not otherwise eligible to receive such care may be obligated to reimburse the U.S. Government.

Child’s Name: Age

Child’s Name: Age

Executed this ___________ day of _______________________, 2011

Printed Name: ________________________ Signature:____________________

(Adult Friends and Family Day Cruise attendee or parent/guardian of minor attendee)

I hereby certify that I am the parent or legal guardian of the child(ren) listed above and authorize the children listed above to embark and disembark on board USS George Washington (CVN 73), in Yokosuka, Japan.

Signature: ____________________ Date: _____________________

(Father/Mother/Legal Guardian)

FOR OFFICIAL USE ONLY- Privacy Sensitive- Any misuse or unauthorized disclosure may result in civil and criminal penalties.

Name: ______________________ M/F: ________ Age: *

(Last name, First name, MI)

Address: _________________ Phone Number: (_________)

E-mail Address:

Sponsor’s Name: _____________________Rank/Rate: _____________Last 4 SSN:

Sponsor’s Dept/Squadron: ___________Division: _________________ Ship J-dial:_____________

PRIMARY ALTERNATE

Name Name

Phone# Phone#

Relationship Relationship

I the undersigned hereby affirm that I (or the above-named minor child in my care) do not have any of the following Physical and/or Medical conditions: Coronary heart disease with symptoms; pacemaker; heart attack within the last six months; current use of blood thinner medications (Heparin, Lovenox, Warfarin or Coumadin); epilepsy or seizure disorder; active tuberculosis, hepatitis, chicken pox, or any other communicable diseases; severe arthritis; severe asthma or severe restrictive airway disease; chronic lung disease requiring supplemental oxygen; movement requiring a walker, crutches, cane, wheelchair, or cast (leg, foot, arm, etc); unable to walk up and down ladders/stairs without difficulty; any limitation in the normal ability to walk or climb.

I further represent that I (or the above-named minor child in my care) am/is not pregnant.

I further represent that I (or the above-named minor child in my care) possess(es) sufficient mobility and stamina to meet the physically demanding requirements to move about the ship in an emergency.

I (and/or the above-named minor child in my care) further acknowledge and will comply with the following: Persons with insulin-dependent diabetes must stay on their usual diet and insulin schedule. Persons must carry all necessary medications with them. Persons must understand that medication storage is not available on board the ship. Persons prone to motion sickness should take motion sickness medication before arriving in the morning, and bring extra medication with them. Persons who have experienced heat exhaustion or heat stroke are strongly cautioned to drink plenty of fluids both before and during the cruise.

If I have any question about whether my physical or medical condition can be accommodated onboard without endangering myself or others, I will contact the Medical Department representatives, CAPT LaVan or LCDR Waterman, at gwfamilycruise@cvn73.navy.mil for clarification and approval.

Executed this ___________ day of ________, 2011

Printed Name: Signature:

(Adult Friends and Family Day Cruise attendee or parent/guardian of minor attendee*)

* For minor children NOT ACCOMPANIED BY LEGAL GUARDIAN, please see attached Friends and Family Day Cruise Legal Note:

FOR OFFICIAL USE ONLY- Privacy Sensitive- Any misuse or unauthorized disclosure may result in civil and criminal penalties.

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If you are planning to bring a minor (age less than 18) who is not your child on the Friends and Family Day Cruise, then you will be required to have a medical care Power of Attorney from that minor's parent/lawful guardian allowing you to authorize medical treatment for the minor. Please contact your local legal office to obtain appropriate document(s). It may be notarized anywhere there is a civilian notary public, such as at a bank or a military legal assistance office (so long as the parent/lawful guardian is eligible to receive military legal assistance).

This form must be completed, properly notarized, and received by the Friends and Family Day Cruise Committee no later than 20-Aug-2011.

It is your responsibility to ensure that a Medical Care Power of Attorney is executed and received prior to the deadline.

It is extremely important that you meet this deadline and submit the Power of Attorney well in advance of the cruise.