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Parent/Guardian Release Form

MTSU Expanding Your Horizons
Middle Tennessee State University
Parent/Guardian Release Form
September 20, 2014

All fields are required. If not applicable indicate with “NA”.

First Name of child:
Last Name of child:
Name of Parent/Guardian:
Street Address of Parent/Guardian:
City:
State: Zip Code:
Home Phone with area code:
Email:
Contact Phone Number During Conference:
Name of Emergency Contact Person:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:
Relationship to EYH Participant:

Does your child have special needs that necessitate accommodations or assistance for any of the following

Visual Yes    No
Auditory Yes    No
Mobility Yes    No
Wheelchair Access Yes    No

Note to Parents and Guardians concerning Accommodation:

Other medical/health concerns (if there are none indicate with "N/A"):

If a special needs situation arises after you register, please contact 615-494-7763.

Which school do you attend?
Grade:

MTSU EYH LIABILITY RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE 
This activity presents the risk of injury. This exculpatory release confirms that the participant who signs below accepts all aspects of that risk.

  1. I, the undersigned parent/guardian, hereby voluntarily expressly and affirmatively execute this agreement in return for permission for my child to participate in the MTSU Expanding Your Horizons in Science and Mathematics Conference to take place September 20, 2014. I fully understand and appreciate the dangers, hazards, and risks inherent in the activity, which dangers include but are not limited to personal injury or death as a result or accident, act of God, or physical exertion or damage to personal property.
  2. Knowing the dangers, hazards, and risks of such activities, and in consideration of being permitted to participate in the activity, I, the undersigned, agree to assume all the risks and responsibilities surrounding participation in the activity, and in advance release, waive, forever discharge, and covenant not to sue the American Association of University Women Murfreesboro Branch and Middle Tennessee State University, their governing boards, officers, agents, employees, and any students acting as employees (hereafter called the 'Releasees'), from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I may have or that may hereafter accrue to me, arising out of or related to any loss, damage, or injury, including but not limited to suffering and death, that may be sustained by me or by any property belonging to me, whether caused by the negligence or carelessness of the Releasees, or otherwise, while in, on, upon, or in transit to or from the premises where the activity, or any adjunct to the activity, occurs or is being conducted.
  3. I understand and agree that Releases are granted permission to authorize emergency medical treatment, if necessary. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.
  4. It is my express intent that this releasee and hold harmless agreement shall bind myself, the participant, the participant's family, estate, heirs, administrators, personal representatives, or assigns and shall be deemed as a 'Releasee, Waiver, Discharge and Covenant' not to sue the above-named Releasees. I further agree to save and hold harmless, indemnify, and defend Releasees from any claim by me or my family, arising out of participation in the MTSU Expanding Your Horizons in Science and Mathematics Conference to take place September 20 , 2014.
  5. In signing this Release, I acknowledge and represent that I have fully informed myself of the content of the foregoing waiver of liability and hold harmless agreement by reading it before I sign it, and I understand that I sign this document as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written statement, have been made. I further state that I am at least eighteen (18) years of age and fully competent to sign this agreement; and that I execute this release for full, adequate, and complete consideration fully intending to be bound by the same. I further state that there are no health-related reasons or problems which preclude or restrict the participating minors' participation in this activity, and that I have adequate health insurance necessary to provide for and pay any medical costs that may be attendant as a result of injury.
  6. I further agree that this Release shall be construed in accordance with the laws of the State of Tennessee. If any term or provision of this Release shall be held illegal, unenforceable, or in conflict with any law governing this Release the validity of the remaining portions shall not be affected thereby.

I have read the above liability release statement and fully understand and accept all aspects of that risk.

Yes 

Photo Permission: I give my consent for MTSU 2014 EYH Conference to use photos, videos, and/or audio tape that include my daughter for the purpose of publicizing and promoting Expanding Your Horizons. I understand that the images or voice recordings may be published in newspapers or magazines, on the World Wide Web, or be broadcast on television or radio. Names and other private information such as addresses, phone numbers, email or schools will NOT be published. If permission for pictures is not granted, your child will be assigned to a group where no pictures will be allowed and thus will not have a choice of workshops.

I have read the above photo permission statement and accept or decline.

Accept  Decline 

Pre and Post Survey Permission: I give my consent for my child, who is participating in the Expanding Your Horizons in Science and Mathematics Conference (EYH) to participate in a survey which will help us gauge the effectiveness of the MTSU EYH program. This is an optional and anonymous survey. If your child decides to participate, she will be asked to complete a pre-survey, post-survey, and a group evaluation detailing their experience at the conference. Your child's participation will help us to further understand the success of the EYH conference pertaining to their interests in science and math. We will collect no information with this study that will identify your child. Results will also be averaged so that specific results of a particular survey question cannot be traced back to any specific participant. Your child's participation is voluntary. Her decision whether to participate or not will not affect her EYH experience. If your child chooses to participate, she is free to decide not to complete the survey at any time without consequence or penalty.

I have read the above post survey permission statement and accept or decline

Accept  Decline  

Parent or Guardian's name:
Date:

If you have questions about this release form please contact us at 615-494-7763.
After submitting, you will be directed to the National EYH site to indicate workshop preferences.