Minor (under 18) liability and release form

Release and Waiver of Liability Form
and
Parent/Guardian Authorization for a Minor Student


A parent or legal guardian must complete the following authorization form if the student is under 18 years of age.  This form must be in the STEM Summer Camp office in order for the student to attend the session.

Student Name: ______________________________________________  Age (as of 1st day of camp): __________

I, the undersigned, certify that I am the parent/legal guardian of  ________________________________________.  I hereby authorize enrollment of the above named student in the STEM summer Camp in the Foothill-De Anza Community College District in order to permit the student to participate. 

Release/Indemnification.  The Parent/Legal Guardian hereby consent to the above listed participation and release absolutely, forever discharge, hold harmless and covenant not to sue the Foothill-De Anza Community College District, its directors, employees, agents, volunteers and affiliates (herein collectively referred to as “District”) from any and all present or future liability, claims, demands, actions or rights of action, whether asserted by me or a third party arising out of, or in connection with minor student’s participation in the above activity (the “Claims”).  I agree to indemnify and hold harmless the District for any such Claims brought by me or a third party from any costs associated with defending or litigating such claims, including but not limited to attorney fees, costs and legal expenses.

Medical Emergency.*  In the event of any medical emergencies, I authorize the consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that the District Faculty sponsor deems necessary for the safety and protection of the minor student, and agree to be financially responsible for any medical services rendered.  I want the District to know about all current medical problems including psychological difficulties and serious allergies (animal, food, medicine, etc.) and physical limitations as follows:

_____________________________________________________________________________________________
*Important Note:  The District will NOT administer medicine during the program.


Signature
I have read the above and understand its terms and I sign it voluntarily and with full knowledge of its significance.


Name of Parent
/Legal Guardian:                    
    Print Name        Signature        Date

Emergency Contacts
Primary Contact:                    
    Print Name        Telephone/ Cell Phone        Email

Alternate Contact:    
                
    Print Name        Telephone/ Cell Phone        Email

In the event the primary parent contact person cannot be reached, the alternate emergency contact person is designated to act on parent’s behalf.