Waiver I Medical Release Addendum

I, ___________________________________________________________________________________agree that
(PARENT'S OR LEGAL GUARDIAN'S NAME)
____________________________________________________________________________________________
(PARTICIPANT'S NAME)

may participate in the ________________________________________________________ Conference/Camp/Event,

scheduled to begin on _________________________________ and conclude _______________________________

In consideration of participation in this Conference/camp/event, I agree, on behalf of the above named child, his/her heirs and representative to fully and forever release, discharge and covenant not to sue Stephen F. Austin State University, the Board of Regents, the state of Texas, their officers, servants, agents and employees (hereinafter referred to as RELEASES), from any and all liability, claims, demands, damages, actions, of causes of action, whatsoever arising out of or related to belonging to me, whether caused by the negligence of the releases, or otherwise, while participating in such activity, or while in, on, or upon the premises where the activity is being conducted or in transportation to and from said premises.
To the best of my knowledge, the above named child can fully participate in this activity. I am fully aware of risks and hazards connected with the activity, including but not limited to the risks as noted herein, and my child hereby elects to voluntarily participate in said activity, and to enter the above named premises and engage in such activity knowing that the activity may be hazardous to my child. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by my child or any loss or damage to property owned by me or my child, as a result of being engaged in such an activity, whether caused by the negligence of releases or otherwise.
It is my express intent that this release and hold harmless agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns, and personal representative, if I am not alive, shall be deemed as a release, waiver, discharge and covenant not to sue the above named releases. I hereby further agree that this waiver of liability and hold harmless agreement shall be construed in accordance with the laws of the state of Texas.
I understand that the university will not be responsible for any medical costs associated with an injury my child may sustain.
My child and I further agree to become familiar with the rules and regulations of the university concerning student conduct and not to violate said rules of any directive or instruction made by the person or persons in charge of said activity and that I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.
I also understand that I should and am urged by SFA to obtain adequate health and accident insurance to cover any personal injury to my child that may be sustained during the activity or the transportation to and from said activity.
I HEREBY FURTHER AUTHORIZE IN ADVANCE ANY NECESSARY MEDICAL TREATMENT REQUIRED BY THE ABOVE NAMED CHILD WHILE IN ATTENDANCE OF THIS CAMP. I HEREBY GIVE PERMISSION TO THE MEDICAL PERSONNEL TO ORDER INJECTION AND/OR ANESTHESIA AND/OR SURGERY FOR MY CHILD AS NAMED ABOVE. I FUTHER AGREE TO ASSUME RESPONSIBILITY FOR THE COSTS OF ANY SPECIALIZED EVACUATION AND OF ANY MEDICAL CARE AND ACKNOWLEDGE THAT THESE COSTS ARE THE FINANCIAL RESPONSIBILITY OF THE UNDERSIGNED. I ALSO ACKNOWLEDGE THAT I HAVE/WILL NOTIFY THE CONFERERENCE/CAMP/EVENT PERSONNEL OF ANY SPECIAL MEDICAL NEEDS OR INFORMATION REQUIRED BY THE ABOVE NAMED CHILD.
I have reviewed the above information and am aware of the risks involved in participating in the summer camp activities and the possible injuries that may occur. My child freely and voluntarily agrees to participate in the activity listed herein. In signing this release, I acknowledge and represent that I have read the foregoing waiver of liability and hold harmless agreement, understand it and sign voluntarily as my own free act and deed; no oral representation, statements or inducements, apart from the foregoing written agreement, have been made; I am at lease eighteen (18) years of age and fully competent; and I execute this release for full, adequate, and complete consideration fully intending to be bound by same. Also, I understand that all rules and regulations for the conference/camp/event will be enforced and any violation by my child will result in a collect call to the parent or legal guardian with a possible request to come and pick-up my child.

___________
Date Signed

_____________________________
Signature of Parent or Legal Guardian

Emergency Contact Telephone Number: ___________________________________________________________

Health Insurance Policy:________________________________________________________________________

Name: _____________________________________________________________________________________

Policy Number: ______________________________________________________________________________