Template For Parental Consent Form (If Under 18 Years Old) Page 2
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2or harmful to him/her or others, and that he/she is allowed to participate in physical activity, which
includes but is not limited to basketball, non-contact football, calisthenics and weight lifting.
•
I understand that as a participant in the JHU program and related activities, my child will be provided
food and it is the responsibility of my child to ask about ingredients in all food he/she chooses to
ingest, and I have discussed this responsibility with him/her.
•
I authorize the JHU SOURCE office to publish or release to the media any pictures of my child
during his/her time as a participant in an approved JHU affiliated program for promotional or
recognition purposes only.
□
Please check box if you do not consent to this statement. This box, if left
unchecked, means that you do consent to any publications or media release.
Note: The statement regarding the publishing or releasing to the media your
child’s photograph does not hinder the process of your child from becoming a
participant in an approved JHU affiliated program.
•
I, the undersigned, certify that I am the parent or legal guardian of the child (named above) and that I
have the right to make decisions for my child that effect his/her well being. I recognize and
acknowledge that physical injury, accident, illness, death, loss of personal property, or other
contingencies may befall my child as a participant in the JHU program and related activities. I
understand that my child is not in any way required to participate in the program and related
activities, and despite these risks, I want him/her to participate in the preceding. In light of the
preceding and with sufficient knowledge of my child's physical and other conditions and limitations,
if any, I voluntarily assume all responsibility and risk of loss, damage, illness and/or injury to person
or property which my child may, in any way, sustain in connection with his/her participation in the
program and related activities. In consideration of my child's participation in the program and related
activities, I agree to release The Johns Hopkins University and its trustees, officers, employees,
agents and volunteers from any and all liabilities, damages, losses and/or causes of action
(collectively, "Claims") that I or my child may suffer or have, including without limitation, to our
persons or property or both, which arise out of, are related to or in connection with, or occur during,
my child's participation in or attendance at the program and related activities except to the extent any
such Claims are caused by the gross negligence or willful misconduct of the employees of The Johns
Hopkins University. I further agree to indemnify and hold harmless The Johns Hopkins University
and its trustees, officers, employees, and volunteers from any and all Claims arising out of, related to,
or in connection with the program or related activities that are caused by my or my child's negligent
or intentionally tortuous acts and/or omissions.
•
I agree that this agreement shall be governed by the laws of the State of Maryland without giving
effect to any choice or conflict of law principles of any jurisdiction, and if any portion of this
agreement is held invalid, the remainder of the agreement shall continue in full force and effect. .
I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ, FULLY
UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, AND I SIGN IT
VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.
Parent/Guardian's Full Name (please print): _________________________________________________
Parent/Guardian's Telephone No: ________________________________________________________
Signature: _______________________________________________Date: _______________________
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