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Southwestern University

WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT


I have elected to voluntarily participate in the following camp/program at Southwestern University: SU Splash 2013 is a Southwestern University student group program. SU Splash 2013 offers noncredit enrichment courses to 9th-12th grade students. This program is designed to give students a chance to take short courses in a wide variety of topics that are designed and led by Southwestern University students. The program includes check-in and registration and lunch is available for purchase although students may elect to bring their own lunches. Some classes may involve athletic activity, the use of craft/construction tools or involve a field trip. Student participation may be recorded on digital or film photography, videotape, audiotape, or any other medium. Students may only attend classes for which they are registered to attend. Class participants are expected to stay together as a group during this program. Parents may not attend classes. To be held on February 23, 2013 at Southwestern University. ELECTIVE PARTICIPATION: I acknowledge that my participation is elective. RULES AND REQUIREMENTS: I agree to conduct myself in accordance with the rules and requirements of this program or event. INFORMED CONSENT: I have been informed of and I understand the various aspects of this camp, including the dangers, hazards, and risks inherent in camp activities. I understand I could sustain serious injuries, including death as a result of my participation in this program. This could result from actions, inactions, negligence or fault of Southwestern University or others, condition of equipment used, facility conditions, weather conditions, or negligent first aid operations or procedures. I further understand and agree that any injury, illness, property damage, disability, or death that I may sustain by any means is my sole responsibility. RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Southwestern University, including its governing board, directors, officers, employees, agents, volunteers, students for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys fees), arising from any injury to myself or others, property damage or death that may occur as a result of my proceeding with this program. I further agree that Southwestern University and the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent acts. ASSUMPTION OF RISK: I understand that there are inherent risks and dangers associated with participating in camp and program activities and that there are dangers that cannot be fully foreseen. Specifically, the risk of injury while participating in events and activities related to this program that may include, but are not limited to, athletic activities, swimming and other recreational activities, along with campus based workshops, class field trips and dining services (responsibility of the participant).
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Southwestern University

INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys fees), arising from any injury to myself or others, property damage or death that may occur as a result of my proceeding with this camp. PHOTO RELEASE: I hereby authorize Southwestern University (SU SPLASH 2013 student program) and the non-profit organization Learning Unlimited (LU) to publish photographs, video (digital media) taken of me, and my name, for use in Southwestern Universitys or SU SPLASH 2013 student program printed publications and website. I acknowledge that since my participation in publications and websites produced by Southwestern University (SU SPLASH 2013 student program) and LU are voluntary, I will receive no financial compensation. I further agree that my participation in any publication and website produced by Southwestern University (SU SPLASH 2013) and LU confers upon me no rights of ownership whatsoever. I release Southwestern University, its contractors, representatives and its employees from liability for any claims by me or any third party in connection with my participation. Signature of Participant (Parent/Guardian) : ________________________________ PERSONAL MEDICAL INSURANCE: I agree that I have and am currently covered by personal medical health insurance and that I am responsible for any and all medical expenses, health services that I may require as a result of proceeding with this camp program. SEVERABILITY: If any term or provision of this agreement shall be held illegal, unenforceable or in conflict with any law governing this agreement, the validity of the remaining portions shall not be affected thereby. I have read and fully understand the terms of this waiver and release of liability. I understand I have given up substantial rights by signing this agreement, and sign it freely and voluntarily. By my signature, I represent that I am at least eighteen (18) years of age or, if not, that I have secured the signature of my parent of legal guardian as well as my own. __________________________________ Signature of Participant I have read and fully understand the terms of this waiver and release of liability. I certify that I have custody of Participant or am the legal guardian of Participant by court order. I join with Participant in granting a release to Releasees as set forth in detail above. ___________________________________ Signature of Parent/Guardian
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Date: __________________

Date: __________________

Southwestern University
HEALTH AND EMERGENCY INFORMATION 1. Scholar Name: ______________________________________________________________ 2. First person to notify in case of emergency: Name _______________________________________Relationship: _______________ Home Phone: _________________ Work: ______________ Cell: __________________ 3. Alternate person to notify in case of emergency (not in same household): Name _______________________________________Relationship: _______________ Home Phone: _________________ Work: ______________ Cell: __________________ 4. Health Insurance Company Name: ______________

Member Name:_________________________ Member I.D. #_____________________ Group #__________________________Policy #__________________________ 5. Family Physician ______________________________________Phone _______________ 6. Please list all medication that your child takes: ____________________________________________________________________________ ____________________________________________________________________________ 7. Please list all allergies that your child has: ____________________________________________________________________________ ____________________________________________________________________________ 8. Has your child had all childhood immunizations? ____Yes ____No

If No explain ________________________________________________ 9. Does child have any medical conditions that would prevent or limit participation in this program/camp activities? ____Yes ____No. If Yes explain your childs needs: ____________________________________________________________________________

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Southwestern University
MEDICAL RELEASE AND RELEASE OF LIABILITY I, ______________________, hereby give my son/daughter _________________, permission to participate in all SU SPLASH 2013 activities, events, and field trips. I also grant permission for any routine or preventive medical care to be performed as required by an attending physician. I understand that Southwestern University staff/students will contact me, or my alternate emergency contact, in the event of an emergency or sudden illness. I will notify the SU SPLASH 2013 Coordinator of any physical or emotional concerns my son/daughter may have that could prevent or limit participation in any program activities, events, or field trips. I release SU SPLASH 2013, Southwestern University and all their agents, employees, and representatives from any and all liabilities, actions, debts, claims, and demands which may arise from participation in SU SPLASH 2013. This Medical Release and Release of Liability shall be binding on the undersigned, any and all heirs, and personal representatives. The undersigned, as the parent or legal guardian of the above mentioned student (under 18 years of age), hereby executes this document and agrees to be bound by all terms and conditions as stated above. Signify your approval by writing your initials in the space before the statement(s) and signing below:
1. IN THE EVENT OF AN INJURY OR ILLNESS TO THE ABOVE-NAMED STUDENT, I HEREBY AUTHORIZE A REPRESENTATIVE OF SOUTHWESTERN UNIVERSITY TO SECURE EMERGENCY MEDICAL TREATMENT FOR THE ABOVE-NAMED STUDENT FROM ANY HEALTHCARE PROVIDER.

2. I UNDERSTAND THAT I WILL BE FINANCIALY RESPONSIBLE, EITHER WITH PERSONAL HEALTH INSURANCE OR OTHER MEANS, FOR MEDICAL TREATMENT NEEDED BY MY CHILD. 3. I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. 4. I HEREBEY AUTHORIZE THE RELEASE OF MEDICAL RECORDS AND INFORMATION AS WELL AS MEDICAL INSURANCE INFORMATION TO SOUTHWESTERN UNIVERSITY AND HEALTHCARE PROVIDERS AS NEEDED FOR TREATMENT OF INJURIES AND ILLNESS TO MY CHILD. 5. I AUTHORIZE MY CHILD TO SELF-ADMINISTER PRESCRIPTION AND/OR NON-PRESCRIPTION MEDICATION .

Name of Medication: __________________________________________________ Amount (dose) to be taken: _____________________________________________ Time to be taken: ________________________ Frequency: ___________________ Duration of treatment: From: ____________ To: ___________________ Please be sure you provide any medication (non-prescription or prescription) only in the original container with labels intact and legible. Consider supplying small quantities of medication that can be replenished each weekend. I have instructed my child not to make available, provide or give his/her medication to any other student/person. ___________________________________________________________________________ Parent/Guardian Signature Date
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