Authorized Dismissal. My child is at least 16 years of age and will be responsible for his/her own transportation to and from the program. My child may sign himself/herself out at the end of the program activities. Signature of Parent or Guardian: Parent/Guardian Name*: *Please note that only the enrolling parent will be permitted to complete this form.
Authorized Dismissal. My child is at least 16 years of age and will be responsible for his/her own transportation to and from the program. My child may sign himself/herself out at the end of the program activities. Parent/Legal Guardian Name*: Signature of Parent/Legal Guardian: *Please note that only the enrolling parent will be permitted to complete this form. FORT VALLEY STATE UNIVERSITY PROGRAMS SERVING NON-STUDENT MINORS INFORMED CONSENT, VOLUNTARY WAIVER, RELEASE OF LIABILITY AND ASSUMPTION OF RISKS FORM PROGRAM/CAMP INFORMATION: Program/Camp Name: Date(s): Time(s): Location: PARTICIPANT INFORMATION: Name of Participant: Gender: Date of Birth: Phone Number: Address: City: State: Zip: PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A LEGALLY BINDING DOCUMENT. THIS FULLY SIGNED FORM MUST BE SUBMITTED BY A PARENT OR LEGAL GUARDIAN BEFORE ANY CHILD IS ALLOWED TO PARTICIPATE IN THE ABOVE REFERENCED PROGRAM/CAMP. I, the undersigned, wish for my Child (hereafter “Child”) to participate in the above referenced youth program (hereafter “Program”) on the date(s) and location(s) indicated above and, in consideration for my Child’s participation, I hereby agree as follows: I acknowledge, 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 youth program may involve risks and dangers, both known and unknown, and have elected to allow my Child to participate 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 Board of Regents of the University System of Georgia, Fort Valley State University, its Administration, Faculty, Staff, Student Leaders, the Program Staff, and all other officers, directors, employees, volunteers and agents (hereafter “FVSU”) from any and all liability as to any right of action that may accrue to my 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 Camp. This agreement is binding on my heirs and assigns. I, on behalf of my Child, furthermore release, in...
Authorized Dismissal. My child is at least 16 years of age and will be responsible for his/her own transportation to and from the program. My child may sign himself/herself out at the end of the program activities. Signature of Parent or Guardian: Parent or Guardian Name*: *Please note that only the enrolling parent will be permitted to complete this form. Xxxxxxx University Emergency Information Form PERSONAL INFORMATION Name: Address (Street, City, Zip): Phone: Student ID Number (if applicable) INSURANCE COVERAGE Company Name: Policy Number: EMERGENCY CONTACT INFORMATION This person will be contacted in case of any emergency. Name: Phone:
Authorized Dismissal. INITIAL HERE ONLY IF your child will be responsible for his/her own transportation (driving or public transportation) to and from the Program, and may sign himself/herself out at the end of the Program. Signature of Parent/Guardian:
