UNG Connect

UNG Symphonic Band and Wind Ensemble - Minors on Campus Participant Forms

AUTHORIZATION TO ADMINISTER MEDICATION

I. Personal/Medication Information

Date: *

Child's First Name: *

Child's Last Name: *

Child's Age: *

Child's Height: *

Child's Weight: *

Child's Home Address: *

City:

State / Province / Region: *

Postal / Zip Code: *

Country: *

Parent/Guardian Name: *

Home Phone: *

Work Phone: *

Cell Phone: *

Food/Drug Allergies: *

Name of Licensed Prescriber: *

Licensed Prescriber Phone: *

Medication(s):

Dosage:

Instructions (route, frequency, duration, take with food, ect.):

Quantity Received:

Special Storage Instructions:

Does your child require any assistance with his or her medications? If so, please explain:

AUTHORIZATION TO ADMINISTER MEDICATION

Authorization for Medical Care:

I hereby authorize the program staff to administer my child the above-listed medication. I understand that medication, whether over-the-counter or prescription, should be kept in original containers. Prescription medication containers should bear the pharmacy label, date of filling, pharmacy name and address, patient name, name of prescribing practitioner, name of prescribed medication, directions for use and cautionary statements, as originally appeared on the container. When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed. By signing this form I hereby acknowledge that all information is accurate and current, that all pertinent and important medication information is listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in the above information in a timely and reasonable manner. I hold harmless and agree to indemnify the program and The University of North Georgia, as well as the Board of Regents, from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment.

Signature of Parent of Guardian: *

Date: *

MEDICAL INFORMATION & AUTHORIZATION FOR MEDICAL CARE

II. Emergency Contact Information

Person to notify in case of emergency: *

Relationship: *

Contact's Phone Number: *

Contact's Street Address: *

Contact's City: *

Contact's State / Province / Region: *

Contact's Post / Zip Code: *

Contact's Country: *

Insurance Provider: *

Insurance Provider Phone Number: *

Insurance Policy Number: *

Additional instructions for the previous question. (Note: The institution does not offer any form of health, liability, or other types of insurance for participants.)

MEDICAL INFORMATION & AUTHORIZATION FOR MEDICAL CARE

III. Medical Information

Please list any current medical concerns or medical history we need to know about your child (Ex. past injuries, current conditions, physical limitations, etc.): *

List any allergies your child has (Ex. medications, stings, food, iodine, latex, etc.): *

Does your child need any accommodations to safely participate in the program? If yes, please explain: *

MEDICAL INFORMATION & AUTHORIZATION FOR MEDICAL CARE

II: Authorization for Medical Care

I understand that my child is voluntarily participating in a University of North Georgia program. By signing this form I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in my child’s mental, physical, or medical condition before the program begins. I understand that the University of North Georgia does NOT provide medical insurance for my child and that I should consult my child’s physician before allowing my child to participate in this program. In the case of accident or illness, I hereby authorize the program staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hold harmless and agree to indemnify the program, the University of North Georgia, and the Board of Regents from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my child’s participation in such voluntary program.

Signature of Parent of Guardian: *

Date: *

Parent or Guardian Work Phone: *

Parent or Guardian Cell Phone: *

PARENTAL ADVISEMENT OF NON-LICENSURE

This document serves as a notification that the Program operated through the University of North Georgia is not licensed nor is required to be licensed by any agency within the State of Georgia. The program is exempted by the Bright from the Start program through the Georgia Department of Early Care and Learning (DECAL) division. By my signature below, I certify that I have read and understand that the above program is a nonlicensed program.

Participant Name: *

Participant Date of Birth: *

Participant Gender: *

Program/Activity Name: *

Starting Date of Program/Activity: *

Ending Date of Program/Activity: *

Location of Program/Activity: *

Parent/Guardian Name: *

Parent/Guardian Signature: *

Date: *

PARTICIPATION AGREEMENT AND WAIVER

RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE

I, as the parent of the participant in the Program, wish for my child to participate in the Program. In consideration of the services to be rendered by the University in organizing and operating the Program and in consideration of my child’s participation in the Program, I hereby agree to the following:

I understand activities for the Program may include, but are not limited to, the following: travel to, from, and during the Program (by car, bus, or walking); sports-related and other physical activities (e.g. running, hiking, swimming, water sports, etc.); physical exertion such as lifting or moving heavy objects; spending extended periods of time outdoors being exposed to the elements (e.g. sun, wind, rain, insects, other environmental allergens, etc.); and consumption of food and/or beverage.

I understand that certain risks are inherent in participation in the Program. These risks may include, but are not limited to, such things as incidents related to sports-related activities, including sprains, broken bones, cuts, bruises, entrapment, temporary or permanent disability, and/or death; transportation; driver error; adverse weather conditions; theft of personal property or other criminal activity; allergic reactions to food and drink items, insects, and other environmental allergens; exposure to contagious diseases; other physical, mental, and emotional injury; and other risks and dangers, whether known or unknown or reasonably foreseeable.

I understand and agree that the University does not provide insurance to cover medical expenses for injuries that may be sustained by my child or for damage to my child’s personal property, and that the University strongly recommends that I carry my own health, medical, and property insurance for purposes of potential losses related to the Program.

In the event of an accident or serious illness, I hereby authorize representatives of the University to obtain medical treatment and transport for my child on my behalf. I hereby hold harmless and agree to indemnify the University from any claims, causes of action, damages, and/or liabilities arising out of or resulting from the medical treatment or transport. I further agree to accept full responsibility for any and all expenses, including medical expenses, which may derive from any injuries to my child that may occur during my child’s participation in the Program.

I understand that my child’s participation in the Program is entirely voluntary. I fully understand the scope of the activities and the potential risks involved in the Program. I hereby acknowledge that my child’s participation in the Program involves an inherent risk of property damage and/or bodily or personal injury, including death, and I assume all risks. I hereby agree that for the sole consideration of the University allowing my child to participate in the Program, I do hereby release and forever discharge the State of Georgia, the Board of Regents of the University System of Georgia (“BOR”), the University, its departments, agencies and instrumentalities and all of their respective officers, members, employees, and agents, or any of their members individually of any and from all claims, demands, rights, and causes of action of whatever kind or nature, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, resulting from my child’s participation in or in any way connected with the Program. I hereby acknowledge that this Release, Waiver of Liability, and Covenant Not to Sue (“Release”) shall be governed by and construed under the laws of the State of Georgia. I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Georgia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I further covenant and agree that for the consideration stated above, I will not sue the University, the BOR, or any of their respective members, officers, agents, or employees for any claim for damages arising or growing out of any voluntary participation in the Program. I understand that the acceptance of this Release by the University and the BOR shall not constitute a waiver in whole or in part, of sovereign or official immunity by the University or the BOR or their respective members, officers, agents, and employees. This release shall be binding upon me and my heirs, legal representatives, and assigns.

I have read this entire Release, Waiver of Liability, and Covenant Not to Sue, I fully understand it, and I agree to be bound by it.

Parent/Guardian Name: *

Parent/Guardian Signature: *

Date: *

PARTICIPANT CODE OF CONDUCT

The Program has established rules and standards of conduct for all Participants. It is the responsibility of the Parent/Legal Guardian and the Participant to review the Program rules and standards of conduct. Dismissed Participants are not eligible for a refund of any fees or expenses. The Parent/Legal Guardian is responsible for all costs associated with removing the Participant from the Program due to his/her misconduct, including but not limited to transportation costs to return the Participant home.

PARTICIPANT AGREEMENT
I understand that as a condition for participating in the Program I must comply with the Program’s rules and standards of conduct and follow all reasonable direction of the Program Staff. Failure to comply with the Program’s rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my being dismissed from the Program.

PARENT/LEGAL GUARDIAN AGREEMENT
I understand that my child will be subject to the rules and standards of conduct of the Program and the University System of Georgia. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home. I understand that Dismissed Participants are not eligible for a refund of any fees or expenses.

Participant Signiture: *

Date: *

Parent/Legal Guardian's Signature: *

Date: *

PHOTO AND MEDIA RELEASE

Photo/Video/Audio Consent and Release

All persons taking photographs or video/audio recordings on University property or of University events must obtain a signed release form from any student, faculty member, staff person, or individual who is visibly recognizable in the images. Crowd scenes where no single person is the dominant feature are exempt. These rules govern photographs, video recordings, and audio recordings intended for use in any University printed, digital, or online publication of any marketing or public relations nature, such as newsletters, Viewbooks, social media or website postings, promotional items, or other such material. These rules are not in effect when photographs or video are taken of news events, but photographs or video taken for news purposes require a release for reuse in marketing materials.

Is participant under 18 years old? *

Yes

I hereby grant the University of North Georgia, acting through its agents, employees, or representatives (ÔÇ£UniversityÔÇØ), the irrevocable right and permission to take photographs, video recordings, and/or audio recordings of me, including my name, image, likeness, performance, and/or voice (ÔÇ£RecordingsÔÇØ). I agree that the Recordings may be used by the University, including its successors, assigns and transferees, in perpetuity and without compensation to me, for any legitimate purpose on University and other websites and in publications, promotional flyers, educational materials, derivative works, and for any other similar purpose, whether in printed or electronic form, and in any and all other media, whether now known or hereafter existing. I agree that the University will have final editorial authority over the use of the Recordings, and I waive any right to inspect or approve of any future use of the Recordings. I further agree that the Recordings, reproductions thereof, and all plates, negatives, recording tape, and digital files are and shall remain the property of the University. I release and fully discharge the Board of Regents of the University System of Georgia (ÔÇ£BORÔÇØ), the University, and their respective employees, agents, and representatives from any claim, damages, or liability arising from or related to my participation in the Recordings or the UniversityÔÇÖs future use of the Recordings. I will make no monetary or other claim against the BOR, the University, or their respective successors, assigns, or transferees for the use of the Recordings. I have read this entire Consent and Release Form, I fully understand it, and I agree to be bound by it. I represent and certify that my true age is at least 18 years old, or, if I am under 18 years old on this date, my parent or legal guardian has also signed below.

No, I do not grant permission for my/my childÔÇÖs image, likeness or recording to be used in any form, unless necessary for the administration of the program in which my child is participating.

Parent/Guardian Signature: *

Date: *

PICK-UP AUTHORIZATION

Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The above-named child will not be permitted to leave the program with anyone who is not listed below. Authorized individuals must pick up the child in person and may be requested to show identification to program staff. Children will not be released to persons who fail to provide acceptable identification upon request.

I authorize the following responsible persons to pick up my child from the program:

Authorized Person: (First and Last Name) *

Additional instructions for the previous question. Please note that children must be picked up by designated times. If an authorized adult is
unable to be reached, program members will contact the local police department as a last resort to take your child home. If you are not at home, your child will be released to the Division of Family.

Phone Number: *

Relationship to Child: *

Authorized Person: (First and Last Name)

Phone Number:

Relationship to Child:

Authorized Person: (First and Last Name)

Phone Number:

Relationship to Child:

Authorized Dismissal:

My child is at least 16 years of age and will be responsible for his/her own transportation to and from the program. My child may sign himself/herself out at the end of the program activities.

Signature of Parent or Guardian: *

Additional instructions for the previous question. *Please note that only the enrolling parent will be permitted to complete this form.