PLEASE READ THIS DOCUMENT CAREFULLY BEFORE CONSENTING. This is a legally binding document.
This form must be signed/submitted by a parent or legal guardian before any minor child is allowed to participate in the referenced program. By signing/submitting this form, I affirm that I am the parent/legal guardian for minor child.
I wish for my minor child (hereafter “Child”) to participate in the referenced program below (hereafter “Program”) on the date(s) and location indicated above and, in consideration for my Child’s participation, I hereby agree as follows:
I acknowledge, agree, understand and appreciate that as part of my Child’s participation in the Program there are dangers, hazards and inherent risks to which my Child may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further realize that participating in the Program may involve risks and dangers, both known and unknown, and have elected to allow my Child to take part in the Program. Therefore I, on behalf of my Child, voluntarily accept and assume all risk of injury, loss of life or damage to property arising out of training, preparing, participating and traveling to or from the Program.
I, on behalf of my Child, hereby release the Shawnee State University, its Board of Trustees, administration, faculty, staff, student leaders, and all other officers, directors, employees and agents (hereafter “SSU”) from any and all liability as to any right of action that may accrue to me, my Child, my Child’s heirs or representatives for any injury to my Child or loss that my Child may suffer while training, preparing, participating and/or traveling to or from the Program. This agreement is binding on my heirs and assigns.I, on behalf of my Child, furthermore release, indemnify and hold harmless SSU from and against any and all losses, liability, actions, debts, claims, costs (including reasonable attorney fees) and demands of every kind whatsoever, specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim, loss or liability for injury to person or property that my Child may suffer, for which my Child may be liable to any other person, that may or does arise out of my Child’s participation in the Program.
I understand that SSU accepts no responsibility for my Child’s personal property. In the event of an accident or illness, I hereby authorize representatives of SSU to obtain medical treatment for my Child on my behalf. I hereby hold harmless and agree to indemnify SSU from any costs, claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my Child that may occur during his/her participation in the Program.
This AUTHORIZATION AND RELEASE contains the entire agreement regarding the subject matter contained herein between the parties to this agreement and the terms of this AUTHORIZATION AND RELEASE are contractual and not a mere recital. The information I have provided is disclosed accurately and truthfully. I have been given ample time or opportunity to read this document and I understand and agree to all of its terms and conditions. I understand that I am giving up substantial rights (including my right to sue), and acknowledge that I am signing this document freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability to the greatest extent allowed by law. My signature on this document is intended to bind not only myself and my Child but also the successors, heirs, representatives, administrators, and as signs of myself and my Child.
I understand and consent that SSU may photograph, video record, and/or audio record my Child, while my
Child is participating in a SSU program or sponsored program. I release all claim to such audio and video
recordings or photographs or images of my Child to the SSU for use in any manner deemed appropriate,
without compensation to me or my Child.
A PARENT OR LEGAL GUARDIAN MUST SIGN/SUBMIT THIS FORM FOR A CHILD UNDER THE AGE OF 18
If you consent to the above terms and conditions, please fill out and submit the form below.