Registration Form Spots are limited and on a first come first serve basis

Transcription

1 UT Houston Medical School s JAMP Symposium March 27 th or April 17 th, 2015 Registration Form Spots are limited and on a first come first serve basis Please Note: Registration is not complete until you receive a confirmation *High School upperclassmen and college freshmen only* Please return to ms.diversity@uth.tmc.edu by 5pm on March 13, 2015 You will need to fill out both forms--registration and the appropriate waiver (Adult for those 18 and older). Please also plan to wear close-toed shoes and long pants. Please circle which date you plan to attend: March 27 th, 2015 or April 17 th, 2015 Name: Date: School: Grade/Classification: Address: Have you attended a JAMP Symposium before? Yes No When & Where: Are you 18 or older? Yes No If not, please make sure to fill out the Risk Waiver form for Minors. Do you have any food allergies? Yes No If so, please list: Do you request a vegetarian meal? Yes No How did you hear about the Symposium? Please fill out both forms and return to ms.diversity@uth.tmc.edu or Fax: (713) Attn: Ms. Kim Marchand

2 ASSUMPTION OF RISK AND WAIVER OF CLAIMS FOR MINORS PARTICIPANT: (Name and Address) INSTITUTION: The University of Texas Health Science Center at Houston- Medical School DESCRIPTION OF ACTIVITY OR TRIP: JAMP Symposium at UT Houston Medical School Activities in the SCSC and Gross Anatomy Lab, Medical School Campus and Memorial Hermann Hospital Tour LOCATION: Medical School Building, SCSC, Gross Anatomy Lab, UTH Campus, Memorial Hermann Hospital_ DATE(s): _(please circle one) 3/27/2015_or 4/17/2015 I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and am fully competent to sign this Agreement. I give permission for Participant to participate in the above-referenced Activity or Trip. I acknowledge that the nature of the Activity or Trip may expose Participant to hazards or risks that may result in Participant's illness, personal injury or death and I understand and appreciate the nature of such hazards and risks. In consideration of Participant being permitted to participate in the Activity or Trip, I hereby accept all risk to Participant's health and of his/her injury or death that may result from such participation and I hereby release the above named Institution, its governing board, officers, employees and representatives from any and all liability to Participant, Participant's personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to Participant's property and for any and all illness or injury to Participant's person, including his/her death, that may result from or occur during Participant's participation in the Activity or Trip, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from Participant's negligent or intentional act or omission while participating in the described Activity or Trip. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE AN ASSUPMTION OF RISK AND WAIVER OF ALL CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT'S INJURY OR DEATH OR DAMAGE TO PARTICIPANT'S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT'S NEGLIGENT OR INTENTIONAL ACT OR OMISSION. Signature of Parent/Guardian Signature of Witness Address (if different than Participant's) Date Signed

3 ASSUMPTION OF RISK AND WAIVER OF CLAIMS FOR ADULT STUDENTS STUDENT: (Name and Address) INSTITUTION: The University of Texas Health Science Center at Houston- Medical School DESCRIPTION OF ACTIVITY OR TRIP: JAMP Symposium at UT Houston Medical School Activities in the SCSC and Gross Anatomy Lab, Medical School Campus and Memorial Hermann Hospital Tour LOCATION: Medical School Building, SCSC, Gross Anatomy Lab, UTH Campus, Memorial Hermann Hospital_ DATE(s): (please circle one) 3/27/2015_or 4/17/2015 I, the above named student, am eighteen years of age or older and have voluntarily applied to participate in the above Activity or Trip. I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks that may result in my illness, personal injury or death and I understand and appreciate the nature of such hazards and risks. In consideration of my participation in the Activity or Trip, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release the above named Institution, its governing board, officers, employees and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Activity or Trip, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described Activity or Trip. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE AN ASSUMPTION OF RISK AND WAIVER OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION. Signature of Participant Date Signature of Witness Date

4 Release Form for Students I have authorized The University of Texas Health Science Center at Houston ( UTHealth ) or its agents or affiliates to obtain, retain and/or release, in its sole discretion, any and all Media Images of me (audio or video interview or other recording, and/or photograph and/or illustration), including information and/or materials in the Media Images for the purposes of publicizing, promoting, marketing, or advertising UTHealth s activities, programs, and services. I hereby release UTHealth and its agents and employees, and The University of Texas System and its Regents, officers, agents and employees from any and all liability connected with the capture or use of any and all Media Images referenced in the Media Authorization Form for Students. I hereby voluntarily waive all rights, interest or claims for payment in connection with any capture or use of any and all Media Images. If I withdraw my authorization for the capture, use or disclosure of Media Images, this Release will remain in full force and effect. Name Signature Address City State Zip Code Telephone Media Event: Date:

5 Release Form for Adults I have authorized The University of Texas Health Science Center at Houston ( UTHealth ) or its agents or affiliates to obtain, retain and/or release, in its sole discretion, any and all Media Images of me (audio or video interview or other recording, and/or photograph and/or illustration), including information and/or materials in the Media Images regarding my personal and/or medical history, condition(s), and treatment(s) for the purposes of publicizing, promoting, marketing, or advertising UTHealth s activities, programs, and services. I hereby release UTHealth and its agents and employees, and The University of Texas System and its Regents, officers, agents and employees from any and all liability connected with the capture or use of any and all Media Images referenced in the Media Authorization Form for Adults. I hereby voluntarily waive all rights, interest or claims for payment in connection with any capture or use of any and all Media Images. If I withdraw my authorization for the capture, use or disclosure of Media Images, this Release will remain in full force and effect. Name Signature Address City State Zip Code Telephone Media Event: Date: