Request for Proposal P20GB001

ASSUMPTION OF RISK, WAIVER, RELEASE, AND CONSENT FOR NON-STUDENT MINOR PARTICIPATION

ARIZONA BOARD OF REGENTS FOR AND ON BEHALF OF NORTHERN ARIZONA UNIVERSITY

Contracts, Purchasing and Risk Management

("PROGRAM")

928-523-4557

Program Information

THIS DOCUMENT HAS LEGAL CONSEQUENCES. IT MUST BE COMPLETED AND SIGNED PRIOR TO PARTICIPATION. PLEASE READ IT CAREFULLY BEFORE SIGNING.

Program Description and Dates:

Department Contact (name, e-mail, phone):

Program Location:

Specific Potential Risks to Participants:

Minor’s Information

Minor’s Name: Age:

Parent(s)/Legal Guardian(s):

Address:

City: State: Zip:

Phone: Cell: Work:

Emergency Contact: Relationship:

Phone:

Emergency Contact: Relationship:

Phone:

Authorized Pick-Up

Minor will be picked up at the end of the Program or for any authorized time spent off of campus by:

Name: Relationship:

Phone number(s):

Identification will be required to be shown to Program staff by the person who is picking up the Non-Student Minor. If the parent(s)/legal guardian(s) listed above is not the person picking up the Non-Student Minor, add name(s), relationship(s), and phone number(s) of other authorized individuals below.

IN ADDITION TO THE PARENT(S)/LEGAL GUARDIAN(S) LISTED ABOVE, THE FOLLOWING INDIVIDUALS ARE AUTHORIZED TO PICK UP NON-STUDENT MINOR:

Parent/Guardian Agreement

I affirm that I am the adult parent or legal guardian of , a Non-Student Minor under the age of eighteen (18), and I consent to their participation in this Program.

1. Acknowledge and understand the risks associated with participation in the Program.

2. Assume all of the foregoing risks and accept personal and financial responsibility for damages.

3. Agree not to sue and waive claims to the fullest extent allowed by law.

4. Grant permission for photography and use of likeness so long as the Image Release Form is signed.

5. Understand medical treatment limitations and financial responsibility.

6. Consent to emergency medical services as needed.

7. Agree to review Program rules and ensure compliance.

8. Waive and release claims arising when the minor is not under direct supervision.

9. Acknowledge the right to decline, decrease, or cease participation for illness or injury.

10. Understand participation may be reduced or stopped in the interest of safety.

11. Acknowledge reading and understanding the waiver and giving up substantial rights by signing it.

12. No oral or written representations can alter the contents of this document.

Medical Information

Provide a complete and accurate statement of the physical factors that may affect participation in the Program.

Local Physician preferred (if possible): Phone:

Insurance Company (if additional to Program insurance):

Policy: Group Number: Phone:

Please indicate any and all special medical conditions Northern Arizona University may need to know about:

List any allergies, to include but not limited to, any medications, food, insect bites, and stings, and describe allergic reactions:

List any and all medication(s) taken on a regular basis for any reason, to include but not limited to, medication taken for illness(es), allergies, pain and injuries (use additional paper if necessary):

List any additional medical/physical information that Northern Arizona University should be aware of, to include but not limited to fitness level, ability to swim, and mobility or sensory limitations: