Insurance And Liability Waiver Consent Form (Page 2 of 3) in pdf

Aggie Softball Camp

Informed Consent, Photo Release, and Permission for Participation in Activity

Participant’s name: (please print) ____________________________________________________

Activity details: 8:30 a.m. Sept. 25, 2010 – Utah State LaRee & LeGrand Johnson Sotball Complex

Special conditions of activity: Risks and dangers may include, but are not limited to, falls, falling

objects and broken or improperly used equipment, which could result in damage to or loss of prop-

erty, illness or disease, physical or mental injury or death of participant or other persons. Injuries that

may result from participation in this activity may include, but are not limited to, cuts, bruises, sprained

joints, broken bones, psychological trauma, infection, and death.

Medical Condition

Participant should be free from any known physical or health problems that could prevent participa-

tion in the activities associated with the program or activities described above.

Listed below are known allergies and medical or physical conditions that may restrict my participation

in the program (write none if none): ___________________________________________________

________________________________________________________________________________

If these conditions could cause a medical emergency during the program, a medical doctor has to be

consulted prior to the program and a written statement must be obtained from the medical doctor stat-

ing that the condition should not be a problem during participation in the program. The doctor’s state-

ment must accompany this document.

Liability Release

I further agree to release Utah State University, its officers, employees, agents and volunteers from any and all liability,

claims, demands, actions and causes of actions whatsoever for any loss, claim, damage, injury, illness or harm of any

kind or nature arising out of participating in the aforementioned activity whether caused by negligence of releases or oth-

erwise except that for which they are solely responsible.

Photo Release

Participants in USU events are sometimes photographed and videotaped for use in USU promotional and educational

materials. I authorize USU to record and photograph my image and/or that of my child for use by USU or its assignees in

research, educational and promotional programs. I understand these audio, video; film and/or print images may be edited,

duplicated, distributed, reproduced, broadcast, and/or reformatted in any form and manner without payment of fees.

I have read and understand the nature of the activity and its inherent risks and I knowingly

give consent for participation.

________________________________

Participant’s Name (Please Print)

Participant’s Signature

________________________________

__________________

Under 18 years of age -Parent/Guardian Signature

Date

This form must be presented onsite the day of the program or before in order for you to participate.

No exceptions!

Insurance And Liability Waiver Consent Form Page 2