Parent/legal Guardian Release For Minor Participant

MINOR (Under Age 18) PARTICIPANT’S NAME: ______________________________________DATE OF BIRTH:____/____/____CAMP NAME:_______________________________

PLEASE PRINT FIRST AND LAST NAME

FORM A:

PARENT/LEGAL GUARDIAN RELEASE FOR MINOR PARTICIPANT

BY SIGNING THIS DOCUMENT, YOU ARE WAIVING CERTAIN LEGAL RIGHTS. READ CAREFULLY BEFORE SIGNING.*

PLEASE COMPLETE FORM IN BLUE OR BLACK INK

GENERAL RELEASE AND INDEMNIFICATION AGREEMENT

I hereby represent that I am the parent or legal guardian of “PARTICIPANT”, who is under the age of 18. For and in consideration of Florida Institute of Technology

permitting PARTICIPANT to participate voluntarily in a FLORIDA INSTITUTE OF TECHNOLOGY CAMP to be held during 2013 on Florida Institute of Technology campus

in Melbourne, Florida, hereafter referred to as “CAMP”, I hereby expressly assume all the risks associated with the CAMP, and I release Florida Institute of Technology, its

trustees, officers, employees, students, and agents from all claims, demands, suits, causes of action, or judgments which PARTICIPANT or I ever had, now have, or may

have in the future or which our heirs, executors, administrators, or assigns may have, or claim to have against Florida Institute of Technology, its trustees, officers,

employees, students, or agents, arising out of or in any way connected with the CAMP, for all personal injuries, known or unknown, property damages, or claims for wrongful

death, caused by the ACTS, OMISSIONS OR NEGLIGENCE of Florida Institute of Technology, its trustees, officers, employees, students, or agents.

I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS FLORIDA INSTITUTE OF TECHNOLOGY, ITS TRUSTEES, OFFICERS, EMPLOYEES, STUDENTS, AND

AGENTS FROM ALL CLAIMS, DEMANDS, SUITS, CAUSES OF ACTION, OR JUDGMENTS WHICH PARTICIPANT OR I EVER HAD, NOW HAVE, OR MAY HAVE IN

THE FUTURE OR WHICH OUR HEIRS, EXECUTORS, ADMINISTRATORS, OR ASSIGNS MAY HAVE, OR CLAIM TO HAVE AGAINST FLORIDA INSTITUTE OF

TECHNOLOGY, ITS TRUSTEES, OFFICERS, EMPLOYEES, STUDENTS, OR AGENTS, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE CAMP FOR ALL

PERSONAL INJURIES, KNOWN OR UNKNOWN, PROPERTY DAMAGES (INCLUDING LOST OR STOLEN PROPERTY), OR CLAIMS FOR WRONGFUL DEATH,

CAUSED BY THE ACTS, OMISSIONS OR NEGLIGENCE OF FLORIDA INSTITUTE OF TECHNOLOGY, ITS TRUSTEES, OFFICERS, EMPLOYEES, STUDENTS, OR

AGENTS, AND ON FLORIDA INSTITUTE OF TECHNOLOGY'S BEHALF AND IN FLORIDA INSTITUTE OF TECHNOLOGY'S NAME DEFEND AT MY OWN EXPENSE

ANY SUCH CLAIMS, DEMANDS, SUITS, CAUSES OF ACTION OR JUDGMENTS DESCRIBED ABOVE. I ALSO AGREE TO BE RESPONSIBLE FOR ANY

PROPERTY DAMAGE OR PERSONAL INJURIES THAT PARTICIPANT OR I MAY CAUSE BY INTENTIONAL OR NEGLIGENT ACTS WHILE PARTICIPATING IN THE

CAMP.

PHOTO RELEASE

PARTICIPANT AND I hereby grant to Florida Institute of Technology the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of university related photographs or

videotaped images of PARTICIPANT for use in connection with the activities of the university or for promoting, publicizing or explaining the school or its activities. This grant includes, without limitation, the

right to publish such images in the university’s student newspaper, alumni magazine, on the university’s Web site, and public relations / promotional materials, such as marketing and admissions publications,

advertisements, fund-raising materials and any other university-related publication. These images may appear in any of the wide variety of formats and media now available to the school and that may be

available in the future, including but not limited to print, broadcast, videotape, CD-ROM and electronic/online media. All photos taken are without compensation to PARTICIPANT. All electronic or

non-electronic negatives, positives, and prints are owned by the university.

I have read and executed this document with full knowledge of its legal significance.

By checking here, I wish to opt out of any future

communication by the university for informational or marketing purposes.

By: ________________________________________________

___________________________________________________________

Parent/Legal Guardian’s Name Printed

PARENT/LEGAL GUARDIAN SIGNATURE

Date

Minor Participant’s mailing address:

___________________________________________________________________________________________________________________________________________________

Street Address

City/State

Zip

*If you are a Florida Institute of Technology employee or a dependent of a Florida Institute of Technology employee, this release shall not be construed to deny any valid direct or first party insurance claims

which you may have relating to possible death or to any injuries you may sustain while participating in the CAMP.

Rev.8/18/2010