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Release, Waiver, and Authorization for Medical Treatment
I, participant (or participant’s parent/legal guardian if participant is under 18 years old) ____________________________, authorize my (my child’s) full participation in the Science Sleuths Summer Program, including related activities. I understand the activities are not without some inherent risk of injury. In consideration of my (my child’s) right to participate in this activity I agree to release, waive, discharge, agree not to sue, and agree to hold harmless for any and all purposes the Science Sleuths Summer Program, Texas A&M University, The Texas A&M University System or its Board of Regents, and their officers, employees, agents, and volunteers (Releasees) from any and all liabilities, claims, or injuries, including death, that may be sustained while participating in this activity, including traveling to, from, and for the activity, or while on premises owned or controlled by Releasees,
including injuries sustained as a result of the negligence of Releasees. I understand this release does not apply to injuries caused by intentional or grossly negligent conduct on the part of Releasees. I further agree to indemnify and hold harmless Releasees for any loss, liability, claim, or injury caused by me (my child) while participating in this activity, including traveling to, from, and for the activity, or while on premises owned or controlled by Releasees.
I also give my permission for me (my child) to receive any emergency medical treatment by a healthcare professional, including emergency medical transportation, which may be required for injuries sustained by me (my child.) I agree to indemnify and hold harmless Releasees for any costs incurred to treat me (my child), even if a Releasee has signed hospital documentation promising to pay for the treatment.
Participant’s Name:
___________________________________________________
Participant’s Signature ______________________________
Date: _____________
(18 or older)
Parent/Legal Guardian Signature ______________________ Date: _____________
(younger than 18)
I agree to follow all instructions and procedures in order to maintain a maximum level of safety.
Participant's Signature: ______________________________ Date ______________
If the participant has medical insurance, please indicate the:
Insurance Company:
___________________________________________________
Policy Number:
________________________________________________________
Name of Primary Policy Holder:
__________________________________________
State law requires you be informed of the following:
(1) you are entitled to request to be informed about the information about yourself collected by use of this form (with a few exceptions as provided by law); (2) you are entitled to receive and review that information; and (3) you are entitled to have the information
corrected at no charge to you. |
