-
-
-
-
-
-
-
-
-
Will your child be transported to/from programming by another group/organization?
-
-
Does your child have food allergies or medical concerns we should know about? *
-
-
Can your child attend the entire session? *
-
Participant Section
-
Have you been to the Vanderbilt University before? *
-
-
-
-
-
Name of Participating Minor and Activity
I, [ Type Name of Minor’s Parent or Legal Guardian in field below], state that [ Type Minor’s Legal Name in field below] (hereafter referred to as “the minor”) hereby consent to his/her attendance and participation in the Scholar Identity Winter Institute, at Vanderbilt University, occurring on/between June 25, 2019 and June 29, 2019.
-
Name of Minor’s Parent or Legal Guardian
-
-
Permission to Participate and General Release
In exchange for allowing the minor to participate in this event or program, the minor by and through the undersigned, agrees to release from liability, indemnify, and hold harmless the Vanderbilt University, its trustees, employees, agents, volunteers, and/or assigns from any and all claims, demands, losses, expenses, actions or causes of action to the minor’s person or damage to the minor’s property which arises out of or occurs during or as a consequence of the minor’s participation in the event or program, whether or not such injury or damage may have been caused, in whole or in part, by any negligence or want or care on the part of the Vanderbilt University, its trustees, employees, agents, volunteers, and/or assigns.
-
Emergency Treatment Authorization
I authorize the Vanderbilt University to provide routine first aid in case of illness or injury. If a parent or guardian cannot be reached, I give my permission for Vanderbilt University to authorize emergency treatment for my child. I acknowledge that any medical treatment will be my financial responsibility and not that of Vanderbilt University. I also hereby affirm that I have health insurance coverage for my minor child.
-
Emergency Contact
-
-
-
-
Photo/Image Release
I grant permission for photos/images of the minor to be used Vanderbilt University in any Vanderbilt University publications and any other way the University deems necessary and appropriate to promote its activities and mission.
-
Acknowledgement
I, the undersigned, state that I am the parent/legal guardian of the minor whose name appears above. I understand that the above terms and conditions apply to said minor and to myself. I further understand that that said minor cannot participate under ANY circumstances in the above specified event or program without parental consent and that the minor will not be allowed to participate without entering into this agreement. This document is binding upon myself, the said minor, and any person suing on behalf of said minor.
-
*
-
Parent’s/Guardian’s Printed Name and Signature (if under 18)
-
-
I understand this is a legal representation of my signature.
Clear
-
-
Vanderbilt Protection of Minors Provision: Vanderbilt University personnel adhere to Tennessee state law on mandatory child abuse. In addition to external reporting, Vanderbilt has a mandatory internal child abuse reporting procedure. If you have reason to believe abuse or inappropriate behavior has occurred concerning a minor participating in a Vanderbilt University program, please consult the program director, or Risk Management (615-936-5935), or report via the Vanderbilt hotline at 844-814-5935. The Tennessee Child Abuse reporting hotline number is 877-237-0004.
-