Parent/guardian Consent-Medical Release And Release From Liability Agreement Form printable pdf download

Parent/Guardian Consent, Medical Release and Release from Liability Agreement

Please read the following information carefully before signing.

All blanks must be completed. Please read the following information carefully before signing.

Activity: ______________________ Activity Time Period: ___________________

Activity Sponsor: _____________________

Participant Name: ________________

Parent/Guardian Name(s):________________________________________________

In consideration for allowing Participant to participate in Activity, I/we, as parents and/or guardians

of Participant, agree to the following:

Authorize Participant to participate in the Activity for the Activity Time Period stated above.

Release, indemnify and hold harmless the Activity Sponsor and University from any and all damages,

except for damages caused by the sole gross negligence or intentional misconduct of Activity Sponsor

or University, arising out of the participation of Participant in the Activity.

Prior to the commencement of the Activity, I/we were made aware of the nature of the Activity, had

sufficient opportunity to inquire further, and understand the Activity has inherent risks and I/we and

Participant assume, on behalf of Participant, all those inherent risks.

While participating in the Activity, Participant is subject to the policies, rules and regulations of the

University and Activity Sponsor. Possession of fireworks, explosives, any weapon, illegal drugs or

alcohol is prohibited and cause for immediate expulsion from the Activity. Further, any Participant

repeatedly disobeying University or Activity Sponsor policies, rules or regulations may be expelled from

the Activity.

Authorize Activity Sponsor, its employees, clinicians, trainers, nurses and agents (collectively, “Activity

Sponsor”) the authority to seek, obtain, and approve any medical care and treatment including, but not

limited to x-ray examination, anesthetic, medical, dental or surgical diagnosis, or treatment and medical

care which may be recommended and provided under the general supervision of any physician or

surgeon, for Participant which, in their judgment, is necessary for the health and well-being of Participant

during his/her participation in the Activity. I/We further agree that I/we are(am) solely responsible for

any costs incurred and agree to hold the Activity Sponsor and the Regents of the University of Michigan,

their employees and agents (collectively, “University”) harmless for any liability arising out of any good

faith action taken in obtaining medical treatment for Participant.

The above agreements are binding upon us, our estates, heirs, representatives and assigns.

Parent/Guardian Signature

Date ____________

Parent/Guardian Signature

Date ____________

Participant Signature

Date ____________

C:\Documents and Settings\robertm\Desktop\Medical Forms Revised 120308.doc

Parent/guardian Consent-Medical Release And Release From Liability Agreement Form