WESTMONT COLLEGE
CONSENT FOR EVENT ACTIVITIES AND TREATMENT

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PARTICIPANT
EVENT INFORMATION
MEDICAL INFORMATION
Leave blank where not applicable.
PARENT/LEGAL GUARDIAN
If Participant a minor; preferred contact otherwise.
MEDICAL PROFESSIONAL
AUTHORIZED ADULTS

    
CONTACT I
CONTACT II
Behavioral Management
I understand that:
a) behavior which disrupts the program or poses a threat to the safety of self or others will not be tolerated;
b) if Participant is unable to self-regulate their behavior then, after the event sponsor (or its agent) has made a good faith effort to resolve the issue (and, if Participant is a minor, consult with a parent or legal guardian), Participant may be removed from the remainder of the event; and
c) in such case there will be no refund of fees.
Authorization for Medical Care
If an injury or illness requires, in the opinion of the person in charge, urgent medical or dental examination or treatment, I authorize and direct that person (or their agent) to:
a) arrange transportation by car or ambulance to the closest hospital;
b) call the Medical Professional/s named above; and
c) attempt to reach one or more of the other listed contacts.
If a named Medical Professional is unavailable, I authorize any emergency treatment deemed necessary by a medical professional licensed for the required service.
Acceptance of Circumstances & Assumption of Risk
I understand that Westmont College assumes no financial responsibility or legal liability for medical care or ambulance transportation. I also verify that the Participant is in sufficient health to be able to participate in the event identified above. I recognize that all physical activity has some risk of injury.
Image Release
I authorize the use, in future program publications, of biographical, image, video or audio content recorded for or during event activities and include this Participant.
Electronic Signatures
A signed copy of this waiver submitted via this form shall be deemed to have the same legal effect as delivery of an original executed copy of this waiver for all purposes.
SIGNATURE


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