Fillable Program Release And Permission To Treat Form (Sam Houston State University)

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Program Release And Permission To Treat Form (Sam Houston State University)

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The Program Release And Permission To Treat Form (Sam Houston State University) form is 2 pages long and contains:

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  • 4 check-boxes
  • 17 other fields

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File type: PDF

U.S.A. forms for Sam Houston State University

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Recreation programs involve participation in outdoor and indoor activities, which are, by their nature, physically demanding. Therefore, all
participants must indicate any medical or physical conditions that might create special considerations for themselves and others. Physical
strength is not required; although being in good condition will increase your enjoyment of the program activities. If there is any doubt about
your ability to safely participate in the program activities, you should consult your physician prior to submitting this form. This information is
confidential and to the extent allowed by law will only be shared with Outdoor Recreation staff to make your experiences as safe and enjoyable
as possible. Thank you for your full disclosure.
Name of Participant: Student ID#: DOB:
Emergency
Contact Name: Relationship:
Primary
Phone # : Secondary Phone #:
Known
Allergies:
Do you carry an EpiPen or Epinephrine?:
_____ No _____
Yes
Relevant
Health Conditions:
Current Medications (include all prescriptions and over the counter medication):
Excluded Activities/Restrictions:
Permission to treat: ___ Participant is 18 years of age or greater ___ Participant is under the age of 18
Participant or participant’s parent hereby represents that participant is physically capable and, if under the age of 18
has permission, to engage in all physical activities unless
otherwise noted above. I hereby give permission to the
medical personnel selected by the designated SHSU authority , to order medically
necessary tests, treatment,
and transportation for me/or my child. In an emergency, if the emergency contact named above cannot be reached,
I hereby give permission to the physician selected by SHSU to administer treatment,
including hospitalization deemed
medically required, for me/ my c hild. I hereby release and hold harmless Sam Houston State University, the Texas
State University System, their regents, employees and volunteers (the “released parties”) from any and all claims,
causes of action, damages, injuries, or losses of any kind whatsoever that may result, directly or indirectly from any
decisions or actions of released parties.
Please return this form and waiver by mail to:
Bearkat Camp
Sam Houston State University
Box 2387
Huntsville, TX 77341
Continued on reverse
Signature Date
Sam Houston State University Permission to Treat
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ASSUMPTION OF RISK
I/my child plan to participate in the Sam Houston State University (SHSU) sponsored activity described above. I have been
briefed about safety consciousness and preparedness during the above mentioned activity. I am aware that I/my child
has a personal duty and responsibility to exercise
common sense and to follow the safety standards, guidelines, and
procedures
established by the SHSU authority. I/my child will notify the SHSU authority if, at any point during the activity,
I/my child questions knowledge of such standards, guidelines and procedures and/or ability to participate in the activities
without
risk. I/my child is am aware that this activity may be led by an undergraduate
student(s). I/my child is am aware
that the use of alcohol, illegal drugs or the illegal use of legal drugs is prohibited and is
grounds for dismissal from this
activity and/or additional disciplinary action. I/my child is aware that participating in this
activity includes exposure to
inherent risks including, but not limited to, PERSONAL INJURY, DEATH,
or PROPERTY DAMAGE. I accept these risks. I
also affirm that I/my child currently have medical insurance.
I/my child is voluntarily participating and accept all risk and responsibility.
WAIVER AND RELEASE
In consideration of the permission given by Sam Houston State University (SHSU) to participate in the
above mentioned
activity, I, (for myself, my heirs, executors, and administrators), RELEASE, DISCHARGE, AND
AGREE TO INDEMNIFY SHSU,
the Board of Regents, Texas State University System, the trip leader(s), and all
of the university’s and Regents officers,
agents, volunteers and employees (the released parties) FROM ANY
AND ALL LIABILITY ARISING from or in connection
with my/my child’s participation in the above-mentioned activity,
REGARDLESS OF WHETHER SUCH LIABILITY IS CAUSED
BY THE NEGLIGENCE OF THE RELEASED
PARTIES. I INTEND THAT THE INDEMNITY PROVIDED IN THIS WAIVER AND
RELEASE IS INDEMNITY
BY ME AND MY CHILD TO THE RELEASED PARTIES FROM THE CONSEQUENCES OF THIER
NEGLIGENCE,
WHETHER THAT NEGLIGENCE IS THE SOLE OR A CONCURRING CAUSE OF THE LIABILITY.
I have been informed and understand the risks and dangers inherent in the above described activity and
that I
participate freely and without guarantee or compulsion. I am of lawful age and legally competent
and empowered to
execute this affirmation, waiver, and release on my own behalf.
MEDIA RELEASE
I understand that photos and/or video taken of me/my child may be used for the purpose of promoting Sam
Houston State
University (SHSU) and various programs of the institution in media that may include printed
material, web and/or
video. I agree to allow my/my child’s image to be used for this purpose and that any
likeness of me may be disseminated
for public release by Sam Houston State University (SHSU).
I HAVE READ AND UNDERSTAND THIS DOCUMENT,
AND AGREE THAT IT WILL LEGALLY BIND ME AND MY ESTATE.
Signature of Participant Date
Signature of Parent or Legal Guardian (if under 18) Date
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Program Release And Permission To Treat Form (Sam Houston State University)

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Completed 24 July 2020

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