UNIVERSITY OF UTAH
IMPORTANT: THIS IS A LEGAL DOCUMENT,
PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING.
MINOR PARTICIPANT INFORMED CONSENT & PARENT/GUARDIAN CONSENT TO TREATMENT, WAIVER AND RELEASE FOR U OF U EVENT OR ACTIVITY
This Agreement must be completed by the Participant and by Parent(s)/Legal Guardian in order to participate in the activities associated with this program.
Participant (print full name):Â Â ________________________________________________
Program and/or Course:Â Â Â Â Â Â Â Â Â ________________________________________________
Date(s) of Program/Course:Â Â Â ________________________________________________
MINOR PARTICIPANT INFORMED CONSENT
I, the undersigned, am the Participant named above. I am familiar with the curriculum and the activities which take place in the above named Program at the University of Utah (the "Program"). I understand that such participation can include foreseeable and unforeseeable risks and other hazardous activities inherent in the program, which may expose me to illness, injury or death. Knowing of these risks, I freely and voluntarily participate in the Program.
I am also familiar with the rules of conduct and University policies relating to this Program. I agree to abide by the all of the operating procedures, including safety procedures outlined by the Program instructor, plus any directions given to me by an authorized University employee during the course of the Program.
(Signature of Minor Participant age 12-17)
PARENT/GUARDIAN CONSENT TO TREATMENT, WAIVER AND RELEASE
I________________________________ am the parent/guardian of the above named Participant who is under 18 years of age. I am familiar with the curriculum and the activities which take place in the above named Program and hereby give consent for the Participant to participate in the Program. I understand that participation in the Program can include foreseeable and unforeseeable risks and other hazardous activities inherent in the program, which may expose the participant to illness, injury or death.
I state that Participant is free from any known heart, respiratory or other health problems that could prevent Participant from safely participating in any of the activities.
I hereby give my express consent in the event of injury for the University to obtain for the Participant any necessary emergency aid, anesthesia and / or operation, if in the opinion of the attending physician, such treatment is necessary.
I certify that participant has medical insurance (provide insurance information below) and otherwise agree to be personally responsible for costs of any emergency or other medical care that Participant receives. I agree to release, waive, covenant not to sue, and hold harmless the University, and all of their officers, employees and agents (collectively the "Releasees") from the cost of any medical care that Participant receives as a result of participation in the Program.
I further agree to release Releasees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, injury, illness, attorneyâ€™s fees or harm of any kind or nature to me arising out of Participantâ€™s participation in the Program and excepting only such loss, damage or injury as may be caused by the sole negligence of any Releasee. This release extends to any claim made by parents or guardians or their assigns arising from or in any way connected with the aforementioned activities.
I agree that the site of any lawsuit arising out of or related to participation in the Program shall be Utah and that this Agreement will be governed by and construed in accordance with the laws of the state of Utah, without application of any principles of choice of law.
I shall pay any attorney fees or costs incurred by the University in enforcing this Agreement.
If any portion of this Agreement is held to be invalid by a court of law, then it is agreed and intended that all the remainder shall, notwithstanding, continue in full force and effect.
*The University of Utah is committed to protecting minors participating in University programs. If you, as a parent/guardian, have concerns about any misconduct in connection with the above named Event/Program, please contact the Universityâ€™s Office of Equal Opportunity and Affirmative Action at (801) 581-8365.
______________________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ___________________
Signature of Legal Guardian and/or Parent of ParticipantÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Date
______________________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
Emergency Contact Name and Relationship to Participant
Participant has been advised to maintain health & accident insurance to cover the costs of treatment in the event of any injury or illness.
Participant's Insurance I.D. number and insurance carrier, carrier address and phone number:
WAIVER: I, the undersigned participant (and my parent or guardian if I am younger than 18 years of age), intending to be legally bound, do hereby forever release and waive any and all rights, claims, and actions for damages that we, our heirs, executors, administrators, and assigns may have, or that may hereafter accrue against any and all persons, organizations, and other entities associated with the event, including, but not limited to Race Entry, USA Track and Field, sponsors, affiliates, volunteers, Burn Camp 5k, and individual Burn Camp 5k organizers, arising out of or in connection with my involvement before, during, or after the event.
I verify that I am physically fit and sufficiently trained to participate in this event and I assume the risks involved in this activity. I further attest that I will be mindful of traffic along the race course, and hold said sponsors and organizers blameless in any harm that may happen.
I also acknowledge understanding that the charge to my card will show up as Race Entry. I acknowledge that the online processing fees and charitable donations are non-refundable. I also acknowledge that any charitable donations will have 4.97% withheld from the donation to pay credit card and administrative costs.
Race Entry shall not be liable to you for any direct, indirect, special, incidental, consequential or exemplary damages including, but not limited to, loss of profits, goodwill, use, data or other intangible loses. Race Entry does not guarantee the completeness or accuracy of any information contained in, or provided in conjunction with the http://www.raceentry.com website. Race Entry is not responsible for any omissions or inaccuracies, or for the results obtained from this information.
Race Entry facilitates registration for various events, some of which allow participants under the age of thirteen (13). We require a submission of birth date for all registration entries. For children under the age of thirteen (13), parental or guardian consent is required.
You agree that the statutes and laws of the State of Utah, USA, will apply to all matters relating to this Agreement and Waiver. You irrevocably consent that exclusive jurisdiction for any dispute with Race Entry relating to this Agreement and Waiver resides in the courts of Utah, and you further agree and expressly consent to the exercise of personal jurisdiction in the courts of Utah in conjunction with any such dispute including any claim involving Race Entry .
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