Authorization to Provide Informed Consent for a Minor

2019 iDUB Conference Parent Permission — Parent/Guardian Information

Please provide the following information (print or type), read the Parent/Guardian Statement of consent, and provide your signature below.

Conference Date:

Parent/Guardian Name: Relationship to Student:

Street Address:

City: Zip Code: Email:

Day Phone: Insurance Company: Policy #:

Participant’s Physician’s Name: Phone:

Please list any of the participant’s allergies to medication:

Medical Restrictions: Yes No If yes, Explain:

Current Medications: Yes No If yes, Explain:

Dietary Restrictions: Yes No If yes, Explain:

If Unable to reach parent/guardian, please contact:

Name: Relationship to Student:

Day Phone: Evening Phone:

Parent/Guardian Statement of Consent

My child, , has my permission to participate in the University of Washington’s 2019 iDUB conference.

I understand that transportation and lodging will not be provided by the University of Washington for iDUB conference.

I release the University of Washington (UW), and its respective directors, officers, agents, and employees (collectively, “Releasees”) from liability for any loss, damage, injury or illness resulting from my child’s participation in this activity. On behalf of my child and myself, I promise that I will not institute, prosecute, or in any way aid in the prosecution of any claim, demand, action, or cause of action against the Releasees or any of them.

In the case of injury or illness, I authorize UW representatives to seek all necessary medical attention for my child. In such case, I understand that I will be notified as soon as possible and that my insurance carrier or I, am responsible for any and all medical expenses incurred. I remain fully responsible for any action taken by my child.

I also note that—though my child will be accompanied much of the time by the Releasees—that they cannot monitor my child 100% of the time. If the UW discovers that my child has left their group, or has done something to risk their safety or the safety of someone else, I will be called and my child asked to leave the program immediately. I will also take full responsibility for any property damage expenses caused by my child in any of the iDUB conference venues.

I further understand that my child’s attendance at the iDUB Program, may involve coverage by the media. I hereby release any claim I may have surrounding rights to my child’s name, image, voice, or likeness, and I agree that the University may use my child’s name, image, voice or likeness in connection with publicity for the University of Washington and its recruitment efforts.

I verify that I have read and understood this document and agree to its terms.

To request disability accommodations, contact the Dasability Services Office at least ten days in advance of the event: (206) 543-6450 (voice); (206) 543-6452 (TTY); (206) 685-7264 (fax); dso@u.washington.edu (e-mail).

Conduct/Liability Form

I, , as a parent or guardian of the iDUB conference attendee , recognize that this conference is made possible with the contributions of the University of Washington, Office of Minority Affairs & Diversity (OMA&D). As a parent/guardian of a participant of iDUB, my child’s conduct must reflect a sincere appreciation of OMA&D efforts. I understand that my child's attendance at this conference is contingent upon their appropriate conduct.

My child promises that while at iDUB conference, they will:

1. Act in a respectful and professional manner at all times.
2. Respect individual privacy and comfort.
3. Be aware of and preserve the safety, health and welfare of other individuals.
4. Refrain from conduct that will cause any damage to facilities or equipment during the ride to and from the conference.
5. Refrain from conduct that will cause any damage to facilities or equipment during the conference.
6. Refrain from the consumption or be in the presence of any illegal drugs and/or alcohol.
7. Participate in all activities within the iDUB conference.

I agree to assume full responsibility for any risk of injury, death, or property damage arising out of my child’s participation in the conference and I give permission for them to receive, if necessary, emergency medical services by authorized personnel, and that any cost incurred as a result of such medical emergency will be solely my responsibility.

I release the University of Washington’s Office of Minority Affairs & Diversity and their affiliates from any liability on account of injury or death arising out of my child’s participation in iDUB conference activities and hold the Office of Minority Affairs and Diversity and their affiliates harmless of any damage or costs that may incurred due to my child's participation in this conference.

I have read and understand the above and understand that UW OMAD reserves the right to expel my child from the conference if they do not live up to this agreement. If for any reason my child is expelled from the conference, I as a parent will be held responsible for any transportation cost resulting from sending my child home.

I further understand that my child’s attendance at the iDUB conference may involve coverage by the media. I hereby, release any claim I may have surrounding rights to my child’s name, image, voice or likeness and agree that the University may use my child’s name, image, voice, or likeness in connection with publicity for the University of Washington and its outreach and recruitment purposes.

To request disability accommodations, contact the Dasability Services Office at least ten days in advance of the event: (206) 543-6450 (voice); (206) 543-6452 (TTY); (206) 685-7264 (fax); dso@u.washington.edu (e-mail).