Women's Soccer ID Clinic

MEDICAL AUTHORIZATION AND EMERGENCY CONTACT

Emergency Contact First and Last Name

Relationship to Student

Other

Phone Number (where emergency contact can be reached)

Alternate Phone Number

Hospital/Clinic Preference

Insurance Company

Policy Number

Physician's Name

Allergies/Special Health Considerations
Please indicate if not applicable.

Medications (name, dosage, frequency, conditions)

My son/daughter has permission to engage in all St. Ambrose University Summer Camp activities.

In the event of an urgent medical matter and I cannot be reached, I hereby give permission to the St. Ambrose University Summer Camp official and/or his/her designee to secure and authorize in my absence any and all medical treatment he/she deems necessary, including but not limited to Emergency Department treatment, laboratory tests, radiological test/procedures, intravenous fluids, medications,
physician services, and/or surgical procedures, for my child named above. In addition, I give my permission for the St. Ambrose University Summer Camp official and/or his/her designee to exchange information regarding my child’s medical history and current medical/health status with the physician and medical facility staff.

By checking this box, you agree to and abide by the Parent/Guardian Consent Statement.

I agree

By checking this box, you agree that everything submitted on this form is factual and true to the best of your knowledge.

I agree

WAIVER AND RELEASE OF ALL CLAIMS

This form provides important information about the St. Ambrose University Summer Camp Programs (called the “Program”) offered by St. Ambrose University, during the months of June through August and taking place on the campus of St. Ambrose University in Davenport, Iowa.

As a student of the Program (a “Participant”), and as a parent/legal guardian of a Participant, it is important that you read this Agreement carefully and be aware that by signing this Waiver and Release of All Claims and participating in the Program, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you might sustain as a result of any and all activities connected with and associated with the Program.

Voluntary Participation: I wish to participate in the Program. I am not being forced in any way to take part in this Program.

Assumption of Risks of Program: I understand that participation in the Program may involve inherent risks and I am also aware that hazards may exist which may be marked or unmarked and occur without warning, and that monitoring and enforcement of the rules by St. Ambrose University does not and cannot guarantee the safety of the Participants. The risks of the Program include, but are not limited to:

• Hazard of travel by bus, van, boat or other forms of transportation
• Local health and weather conditions
• Injury resulting in serious, permanent physical injury, or even death, resulting from accident, natural disasters or acts of God, from strikes, ware, quarantine or government restrictions, from medical care of treatment received or from the lack of medical services.
• Potential of criminal or injurious acts by others
• Physical exertion or emotional distress
• Injury resulting from the handling of sharp instruments, dissection related activities, and exposure to laboratory chemicals
• Exposure to infectious, communicable and other diseases
• Exposure to allergens, whether known or unknown
• Loss of valuable property
I acknowledge that not every risk or possibility can be foreseen, and that the omission of a risk does not in any way limit the enforceability of this agreement. KNOWING THE RISKS DESCRIBED ABOVE AND OTHER POTENTIAL RISKS NOT LISTED HERE, AND IN CONSIDERATION OF BEING ALLOWED TO PARTICIPATE IN THE PROGRAM, I HEREBY ASSUME ALL RISKS AND RESPONSIBILITIES SURROUNDING MY PARTICIPATION IN THE PROGRAM, OR MY WARD/CHILD’S PARTICIPATION IN THE PROGRAM.
Waiver, Release and Indemnification: I AGREE TO RELEASE, INDEMNIFY AND HOLD HARMLESS ST. AMBROSE UNIVERSITY, ITS OFFICERS, DIRECTORS, TRUSTEES, AGENTS, AND EMPLOYEES (“RELEASES”) FROM ANY AND ALL LIABILITIES, CLAIMS, OR DEMANDS OF ANY NATURE WHATSOEVER, FOR PERSONAL INJURY, PROPERTY DAMAGE OR OTHER LOSS OF ANY KIND THAT I MAY SUSTAIN, AND THAT MY WARD/CHILD MAY SUSTAIN, AS A DIRECT OR INDIRECT RESULT OF PARTICIPATION IN THE PROGRAM, EVEN IF SUCH LOSS RESULTS FROM THE NEGLIGENCE OF THE RELEASEES (EXCEPT FOR CLAIMS OR LIABILITY ARISING DIRECTLY FROM THE GROSS NEGLIGENCE OF RELEASEES). I UNDERSTAND THAT BY SIGNING THIS DOCUMENT, I AM GIVING UP MY LEGAL RIGHT TO SUE TO RECOVER DAMAGES FOR CLAIMS THAT I MIGHT HAVE.

Institutional Arrangements: I understand that St. Ambrose University does not represent or act as an agent for, and cannot control the acts or omissions of any transportation carrier, hotel or other provider of goods or services involved in the Program.

Insurance: I understand that all Participants are required to carry accident and medical insurance.

Standards of Conduct: I understand that Participants are responsible for their own conduct. I agree to comply with all the rules, regulations and policies of St. Ambrose University, including those (if any) specifically pertaining to the Program. I further understand that the “Participant Conduct Agreement”, which I have been provided, outlines conduct and expectations for the Program.

Supervision and Activities: I understand that not all activities associated with the Program will be supervised. The Program includes time periods during which I can choose to participate in various recreational activities. I agree to comply with all rules and procedures during this discretionary time. I understand that St. Ambrose University is not responsible for any injury or loss I may suffer, and I understand that the risk of injury might increase if I separate from the Program and group activities, whether temporarily or for a longer term.

Off Campus Travel: I understand that the Program may involve off-campus travel. I agree to stay with the Program at all times during any off-campus travel. I also understand that the same rules and regulations apply to off-campus travel.

Valuables: I understand that I am solely responsible for keeping safe any money, jewelry and other property. St. Ambrose University, the Program Director(s) and/or other employees and agents acting on its behalf are in no way responsible for safeguarding any of my personal belongings.

Program Changes and Refunds: I understand that St. Ambrose University reserves the right to make changes to the Program. I also understand that Programs may be cancelled. Participants of cancelled Programs will receive a full refund upon program cancellation. Refunds will be made within a timely manner.

Withdrawal: I understand that if I withdraw from the Program for any reason (after the payment deadline date), or if I am involuntarily dismissed from the Program based on my conduct, I will receive no refund.

Fitness to Participate: I have or will provide the St. Ambrose University Summer Camp Program office with a signed medical release form (along with a copy of the insurance card which the Participant is insured under) and hereby re-affirm that I am physically and mentally fit to participate in the Program.

Medical Treatment Authorization: St. Ambrose University, its officers, directors, trustees, agents, and employees, is authorized (but not obligated) to take any action (including notification of my parents or guardian) it considers to be warranted under the circumstances regarding my health and safety. I agree to reimburse St. Ambrose University for all expenses related thereto and hereby release St. Ambrose University, its officers, directors, trustees, agents and employees, from any and all liability for such actions and/or for payment for such authorized treatment.

Photo Release: I grant permission to St. Ambrose University to photograph me and to use those images in any printed or electronic media. I understand that the photographs will be the property of St. Ambrose University and that I will not be notified when the photographs are used, nor will I have the opportunity to view and approve the photographs prior to their publication.

Binding Effect; Construction: Forum: I acknowledge that this agreement will bind members of my family, my spouse, heirs, assigns and personal representative(s). This agreement will be construed under the law of the State of Iowa, which will be the forum for any lawsuits filed under or incident to this agreement or to the Program. Should any part of this agreement be rendered or declared invalid by a court of competent jurisdiction, such invalidation or such part or portion of this agreement should not invalidate the remaining portions thereof, and they shall remain in full force and effect.

By checking the box below, you signify that you have read and understand the terms of this Waiver and Release of All Claims. You understand that by checking the box below that you give up your legal right to sue to recover damages for claims you might have.

I have read and understand the agreement.