Student Activity Participation Agreement Form
Student Activity Participation Agreement, Release Waiver and Permission To Secure Treatment
First Name
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Last Name
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Cell Phone (in case we need to contact you while you are traveling)
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Email
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Emergency Contact Name
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Emergency Contact Phone Number
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Will the student be under 18 years of age during the upcoming semester?
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- Please Select -
Yes
No
I certify that the information entered here is accurate, and that my electronic signature is the equivalent to my handwritten signature.
PATRICK HENRY COLLEGE
STUDENT ACTIVITY PARTICIPATION AGREEMENT
RELEASE WAIVER AND PERMISSION TO SECURE TREATMENT
I, the undersigned student, acknowledge that I may choose to participate in any and all, current and future, Patrick Henry College sponsored activities (hereby known as the “Activity”) to include, but not limited to, an athletic team, apprenticeships/internships, sponsored club or organization, and service/project. I am choosing to participate in this Activity and I assume and accept the responsibility for my involvement in this Activity.
I acknowledge that participating in any such Activity involves certain risks and that injury, death, property damage, or other harm could occur to me or others. I agree to assume the full risk of any injuries, damages, or harm which arise during or as a result of my participation in any such Activity.
In consideration of the College’s efforts in making any such Activity available and my being allowed to participate, I hereby agree to release, indemnify, hold harmless and forever discharge Patrick Henry College, its trustees, officers, employees and agents, from any and all claims and causes of action which might be brought by me or my parents on my behalf for loss of property, personal injury or death sustained by me arising out of any travel or activity conducted during the period of my participation in any such Activity.
I agree to reimburse Patrick Henry College any costs it incurs due to injury/damage resulting from my participation in any such Activity, including medical bills, court costs and attorney fees. In the event of an emergency I authorize Patrick Henry College officials to secure treatment from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for my immediate care and I agree that I will be responsible for payment of any and all medical services required.
I agree that as a Patrick Henry College student participating in any such Activity, I am bound by all College rules and regulations regarding student conduct included but not limited to the Student Handbook. I have read and fully understand the aforementioned Participation Agreement, Release Waiver and Permission to Secure Treatment, and all information supplied by me is accurate and current to the best of my knowledge.
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