ST. FRANCIS COLLEGE PERMISSION SLIP 

I, Parent/Guardian First Name  Parent/Guardian Last Name, the parent or legal guardian of Child First Name Child Last Namehereby give my permission for my child to participate in Name of Program on the St. Francis College campus on Date. I understand that there may be dangers and risks associated with my child’s participation in this event, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness or even death. Furthermore, in addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. I wish for my child to participate despite such risks.   

 

 

LIABILITY WAIVER: In consideration for granting this request to participate in the Name of Program and being fully aware of the risks involved, I    Parent/Guardian First Name   Parent/Guardian Last Name   hereby waive any and all legal rights I or my child   Child First Name   Child Last Name have or may have in the future to bring any claim or lawsuit against St. Francis College, its agents, trustees, officers, officials, students or employees and authorized volunteers arising out of or in connection my child’s participation in the Name of Program. 

 

 

HOLD HARMLESS AGREEMENT:IParent/Guardian First Name   Parent/Guardian Last Nameagree to indemnify and hold harmless St. Francis College, its agents, trustees, officers, students, employees and authorized volunteers, from and against any legal actions, claims, damages, losses or expenses arising out of, in whole or in part, any activity associated with my child’s participation in the  Name of Program , including but not limited to claims for personal or bodily injury, disease or death, or injury to or destruction of property.   

 

Further, I agree to indemnify St. Francis College and any of its agents, public officers, officials, students, or employees and authorized visitors for any attorney’s fees and court costs incurred or to be incurred in defending any actions brought against them out of, in whole or in part, my child’s participation in Name of Program . 

 

I have read and understand the above liability waiver and hold harmless agreement. 

The undersigned acknowledges and assumes full responsibility for: 

-Its own personal equipment during use and while stored on St. Francis College’s Campus and 

-Use of campus property 

 

 

MEDIA RELEASE 

 

I hereby give St. Francis College and their legal representatives and assigns, the right and permission to photograph, digitally record, videotape, or audio tape, my above-named child while s/he is attending participating in any program occurring on or off the St. Francis College campus. I further agree that any or all the material recorded may be used, in any form, in publications, including electronic publications, or in audio-visual presentations, promotional literature, advertising, or in other similar ways, and that such use shall be without payment of fees, royalties, special credit, or other compensation. I understand that all such recordings, in whatever medium, shall remain the property of St. Francis College.  

 

 

MEDICAL AUTHORIZATION CONSENT FOR MEDICAL TREATMENT OF A MINOR 

 

I recognize that there may be occasions where the minor child named above, may need first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize any St. Francis College staff member, in whose care the minor child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor by the medical staff of a licensed hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment.  

 

As parent or legal guardian of my minor child Child First Name   Child Last Name , I am responsible for the health care decisions of my minor child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for dental, medical, and/or hospital care or treatment to be rendered to my minor child is legally sufficient and that no consent from any other person is required.  

 

By signing below, I authorize any St. Francis College employee, in whose care the minor child has been entrusted to authorize any hospital or physician or other health care provider to bill the following insurance company or companies for the payment of any services rendered to the minor child. I agree to assume responsibility for the charges for such care as rendered to the above-named minor child.  

 

I authorize any hospital, physician, or other health care provider to release information from the minor child's medical record to the insurance company named below, in connection with the completion of any insurance claim form.  

 

I have read, understood, and agreed to the information above. All releases, authorizations and permission granted above shall remain in effect unless revoked in writing by the undersigned to St. Francis College, 181 Remsen Street, Brooklyn Heights, New York 11201.