Pennsylvania Western University-Californa-Fay-UB-Medical Form

PENNSYLVANIA WESTERN UNIVERSITY-SPONSORED PROGRAM INFORMATIONAL FORM FOR MINORS
PARTICIPANT INFORMATION
Participant's Name:

First NameLast Name
Email:
example@example.com
Date of Birth:

MonthDayYear
mm-dd-yyyy
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
(999)999-9999
Name of Event: TRIO Upward Bound
Academic Year Dates (i.e. 2025-2026):
PARENT/LEGAL GUARDIAN INFORMATION
Name:

First NameLast Name
Cell Number:
(999)999-9999
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL INSURANCE INFORMATION
Insurance Company Name:
Policy Number:
Agreement Number:
Policy Holder Name:
Relationship to Participant:
I, as a legal guardian, have medical insurance coverage for my child and understand that I am responsible for all medical costs associated with injuries, infections, accidents and illnesses that may occur at this University activity.
EMERGENCY CONTACT PHONE NUMBERS

(In the event the parent or guardian cannot be reached)
1st Contact:

First NameLast Name
Relationship to Participant:
Cell Number:
(999)999-9999
2nd Contact:

First NameLast Name
Relationship to Participant:
Cell Number:
(999)999-9999
MEDICAL HISTORY OF PARTICIPANT
1. Any current medical conditions that may be life threatening, result in a medical emergency, or affect participation in activities?
If yes, ___
2. Any allergies to prescription and/or non-prescription medication?
Please list:
Reaction:
3. Any additional allergies (food, insect, etc.)
Please list:
PARENTAL CONSENT TO MEDICAL TREATMENT
PLEASE SIGN the following statement concerning the medical treatment of my child: In the event of any illness or injury to my child I give the University sponsor permission to administer minor treatment, while continuing to contact the parent, guardian, designated individual, or 911 in a medical emergency.
Parent/Legal Guardian Signature:
Date:

MonthDayYear
mm-dd-yyyy
Participant's Name:

First NameLast Name
PENNSYLVANIA WESTERN UNIVERSITY Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Name of Event: TRIO Upward Bound

Waiver: In consideration of being permitted to participate in any way in [Activity/Event Name]: TRIO Upward Bound, hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Pennsylvania Western University, and the State System of Higher Education, part of the Commonwealth of Pennsylvania, and their officers, employees, volunteers and agents from liability for any and all claims including the negligence of Pennsylvania Western University, its officers, employees, volunteers and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity.

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from: 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions; to 3) catastrophic injuries
including paralysis and death.

Representations: I certify that I am in good health and have no mental or physical condition or symptoms that could interfere with my safety or the safety of others while participating in any Activity described above.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Pennsylvania Western University and the State System of Higher Education HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.

Severability: I further expressly agree that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the Commonwealth of Pennsylvania and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Participant's Name:

First NameLast Name
Participant's Age:
Signature of Participant:
Date:

MonthDayYear
mm-dd-yyyy
Signature of Parent/Legal Guardian:
Date:

MonthDayYear
mm-dd-yyyy

PENNSYLVANIA WESTERN UNIVERSITY-SPONSORED PROGRAM INFORMATIONAL FORM FOR MINORS

PARTICIPANT INFORMATION

PARENT/LEGAL GUARDIAN INFORMATION

MEDICAL INSURANCE INFORMATION

EMERGENCY CONTACT PHONE NUMBERS

MEDICAL HISTORY OF PARTICIPANT

PARENTAL CONSENT TO MEDICAL TREATMENT

PENNSYLVANIA WESTERN UNIVERSITY Waiver of Liability, Assumption of Risk, and Indemnity Agreement