Release Authorization (Page 13 of 13) in pdf

PENSACOLA CHRISTIAN COLLEGE

Minor Student Disclosure Statement

(For Admissions Use)

NAME (Please print)

LAST

FIRST

MIDDLE

I.D. NUMBER

I acknowledge that I am responsible to read and abide by the policies of the Pathway, to conform to the standards and

ideals of work and life of PCC, and to be in harmony with the spirit of Pensacola Christian College (“PCC”).

I agree that PCC may, in its sole and absolute discretion, communicate with and disclose to my parents, legal guardians,

and pastor any and all information and details concerning any situation affecting me or my status as a student or summer

worker of PCC. I also agree that PCC’s Graf Clinic, and any manager or operator of the clinic, shall have the right, in its

or their sole discretion, to release and disclose to my parents, legal guardians, and officials of PCC any and all

information concerning my spiritual, emotional, or physical health, including but not limited to my medical records,

whether or not such information would otherwise be confidential or protected by law from disclosure. I further agree to

authorize the release of medical information for any off-campus medical or emotional treatment I may receive, should

PCC’s administration request the information. I release and hold harmless PCC for any liability resulting from the

disclosure of my information for the purposes stated herein, including any and all claims, demands, damages, actions,

causes of action, suits in equity of whatever kind or nature.

I understand that PCC’s Catalog contains current information regarding the calendar, admissions, degree requirements,

fees, regulations, and course offerings, and that PCC reserves the right to withdraw a course at any time; change room

and board, tuition, and other fees; change the calendar and rules regarding admission and graduation requirements; and

change any other regulations affecting the student body. Changes shall become effective whenever the proper authorities

so determine and shall, at the discretion of such authorities, apply not only to prospective students but also to those who

at that time are matriculated in PCC. PCC is accredited by the Transnational Association of Christian Colleges and

Schools. It is the practice of PCC, and other colleges and universities, to accept or reject credits based on their own

institutional criteria regardless of whether or not credits will be accepted by another college of the student’s choice.

While PCC makes no representation that its graduates will be accepted by specific institutions, boards, professional

bodies, or government agencies, it is the intent of the administration and faculty to meet and exceed standards of quality

in academics that are posed by recognized accrediting associations. PCC offers access to its educational programs and

activities based upon biblical standards and applicable laws that permit its right to act in furtherance of its religious

objective. PCC does not discriminate on the basis of race, color, sex, or national origin in administration of its

educational policies, admission policies, and scholarship or loan programs.

I indemnify and save PCC, its employees, and agents harmless from any liability or medical expenses resulting from any

sickness, accident, or injury while participating in any activity on or off campus. If I use any of PCC’s facilities (i.e., the

swimming pool, gym, weight room, tennis courts, sports center, etc.) or participate in any activity, I do so at my own risk.

I understand and agree that PCC is not responsible for my medical expenses and that it does not provide any accident or

medical insurance to cover my medical expenses should I become sick or injured. I am responsible for my own medical

expenses, and I will file any medical claim with my own insurance company or pay the cost myself. I further agree that

should I take any legal action against PCC, its employees, or agents, I will be liable for any attorney fees and court fees,

through all appeals, incurred to defend PCC against such action if it is determined that I am not the prevailing party.

In the event that PCC’s photographer or videographer captures an image or images of me, singularly or in a group, I give

permission for that image/those images to be used in future PCC brochures, videos, or publications.

Any reference to PCC shall also mean and refer to the affiliates, subsidiaries, and related entities of PCC.

_________________________________________________________

________________________

Minor Student Signature

Date

MM / DD / YYYY

_________________________________________________________

________________________

Parent/Legal Guardian Signature

Date

MM / DD / YYYY

RO/jrm

7/5/16

Release Authorization Page 13

Related Articles

Related forms

Related Categories