UVSASE

UVSASE ELEMENT II CONFERENCE WAIVER AND RELEASE FORMS


These forms must be filled out and returned to the UVSASE Element Conference Registration Committee by May 27, 2019 at 11:59pm. Failure to return these for will result in the dismissal of participation from conference.

Electronic Signature Form (required)

ELECTRONIC SIGNATURE AGREEMENT

 

I, the undersigned (Name of Student/Participant) wish to (and if under 18 years of age, also my parent or guardian authorizes to) participate in UVSASE Element Conference.

By clicking the box below, I understand that I am signing this Agreement and the following documents electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Agreement. By clicking the box below, you consent to be legally bound by the terms and conditions of this form. You further agree that the use of your electronic signature constitutes your signature, acceptance and agreement as if actually signed by you in writing.

 

You also agree that no certification authority or other third party verification is necessary to validate your electronic signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your electronic signature.

 

You also represent that you are authorized to enter into this Agreement for yourself and/or persons under 18 years of age and that you will be bound by the terms of this agreement.

Indicate your consent to the term and conditions of this Agreement by clicking on the box below and by signing your name electronically.

 

 

Student/Participant Signature:   

Date:

Parent/Guardian Signature:   

Date:

(If Participant is under the age of 18)

Failure to consent to this electronic signature form will result in the need of the Student/Participant or Parent/Guardian (if participant is under the age of 18) to submit either a scanned copy of these documents with a handwritten signature or a hardcopy to the UVSASE Element Conference Registration Committee before the deadline prescribed above.

 

Participation Waiver Form (required)

ACKNOWLEDGMENT, RELEASE, HOLD HARMLESS AND ASSUMPTION OF POTENTIAL RISK AGREEMENT

 

I, the undersigned (Name of Student/Participant)  wish to (and if under 18 years of age, also my parent or guardian authorizes to) participate in UVSASE Element Conference.

 

I understand and acknowledge that this Activity may be dangerous and hazardous and, by its very nature pose the potential risk of severe and serious physical and emotional injury/illness, or even death, to all individuals who participate in such Activity.

 

I understand and acknowledge that in order to participate in this Activity, my son/daughter and I agree to ASSUME ALL LIABILITY AND RESPONSIBILITY for any and all potential risks, injuries, or even death which may be associated with participation in such Activity.

 

I represent and warrant that Student/Participant is mentally and physically fit, capable, able, and willing to participate in this Activity without any limitations.

 

I understand, acknowledge, and agree that UVSASE, its trustees, agents, volunteers, or representatives shall not be liable for any injury/illness suffered by Student/Participant, which is incident to and/or associated with preparing for and/or participating in this Activity.

 

I hereby release, discharge, indemnify, and agree to hold harmless UVSASE, its governing board, and each of their trustees, employees, agents, coaches, teachers, volunteers, and representatives free from any and all liability arising out of or in connection with Student/Participant’s participation in this Activity, including all related activity such as games, practices, training activities, trips and related exercise. For purpose of this RELEASE, liability means all claims, demands, losses, causes of action, suits, or judgments of any kind that Student/Participant or Student/Participant’s parents, guardians, heirs, executors, administrators, and assigns may have against UVSASE, and their trustees, agents, volunteers, and representatives because of Student/Participant’s personal, physical or emotional, injury, accident, illness, or death, or because of any loss of or damage to property that occurs to Student/Participant or his or her property during Student/Participant’s participation in the Activity that may result from any cause including but not limited to UVSASE’s, trustees’, agents’, volunteers’, or representatives’ own passive or active negligence or other acts other than fraud, willful misconduct or violation of the law.

 

I acknowledge that I have carefully read this ACTIVITIES PARTICIPATION FORM and that I understand the potential dangers incident to engaging in the Activity, am fully aware of the legal consequences of this agreement, and agree to its terms and understand I am waiving certain rights and assuming the risk of damage from my participation in the Activity.

 

The undersigned understands and acknowledges that during the activities pictures, including video, may be taken of the undersigned, or my son or daughter, and with voice sound and may subsequently be used in the promotion of future activities by UVSASE. I authorize the use of my name or my son or daughter’s name, and pictures including any accompanying voice, to be exhibited with or without advertising sponsorship as still photographs, transparencies, motion pictures, television, video or similar media and hereby release UVSASE its trustees, officers, agents, and cooperating agencies from any and all claims for the taking and use of the same.

 

Student/Participant Signature: 

Date:

Parent/Guardian Signature:   

Date:

(If Participant is under the age of 18)

 

A signed PARTICIPATION WAIVER must be on file with UVSASE before a Student/Participant will be allowed to participate in the above Activity. STUDENT/PARTICIPANTS AND/OR PARENTS OR GUARDIANS WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS AGREEMENT SHOULD NOT SIGN THIS AGREEMENT, AND WILL NOT BE ALLOWED TO PARTICIPATE.

 

Medical Release Form (required)

AUTHORIZATION FOR MEDICAL TREATMENT

 

I, the undersigned (Name of Student/Participant) wish to (and if under 18 years of age, also my parent or guardian authorizes to) participate in UVSASE Element Conference.

In order that I/my daughter/son may receive the necessary medical treatment in the event of an emergency whereby I/she/he may sustain injury or illness during participation in this activity, I authorize any school official to consent to and obtain necessary medical treatment, including x-rays, examination, anesthetic, medical or surgical diagnosis or treatment or hospital care for such an injury or illness during the activity and I hereby release, discharge, indemnify and agree to hold UVSASE, governing board and each of their trustees, agents, volunteers, and representative harmless in the exercise of such authority. I further hereby acknowledge that neither UVSASE nor any of the persons named above have any obligation to seek such treatment. Should the need arise, the following information may be given to any health care provider:

 

Emergency Contact #1

Parent(s) or Guardian

First Name: 
Last Name: 
Relationship: 
Phone:   

Emergency Contact #2

Adult Over the Age of 21

First Name:   
Last Name:   
Relationship:   
Phone:   


Student’s primary physician

Name of Physician:   
Phone: 

 

Medical Conditions

 

Please list any medical conditions of the above student (asthma, diabetes, epilepsy, etc.): 

 

Please list any allergies or allergic reactions to foods, materials, or medications of the above student:

 

Please list any medications the above student is now taking:

 

Other pertinent medical information:

 

Medical Insurance

Insurance Provider: 
Policy #:   

I, or the undersigned parent/guardian, have read and understood the above Authorization for Medical Treatment.

 

Student/Participant Signature: 

Date:

Parent/Guardian Signature:   

Date:

(If Participant is under the age of 18)

 

 

ELEMENT CONFERENCE HOUSING RULES AND REGULATIONS

 

Note: There is a ZERO-TOLERANCE policy in place. This policy will encompass all interactions during the course of the Element Conference. If you do not adhere to the rules and regulations below, you will be removed from the conference without a refund. The Element Staff reserves the right to make the final decisions.

 

Safety Procedures

  1. Keep track of all of your personal belongings! Element Staff will not be held accountable for any lost or stolen items.
  2. All attendees must return to dorm facilities after programming has ended.
  3. When the sun sets beyond the horizon, please travel in groups of 2 or more. Do not go anywhere alone.
  4. Please report any suspicious activities to Element Staff as soon as you see them.
  5. Please notify Element Staff if you need any assistance or have any reason to leave the premise.

 

Housing Regulations

  1. Attendees must return and remain in their assigned room before 2:30 AM unless they have notified their designated House contact or any other member of Element Staff.
  2. Attendees may not cook in their rooms. Cooking is restricted to those areas of the residential facilities which have been set aside for that purpose (kitchen areas).
  3. Pets are not allowed in the housing facilities at any time.
  4. Quiet hours will be maintained from 1:00 AM till 7:00 AM. Please keep noise to a minimum during these hours as a courtesy to your neighbors.
  5. Attendees will be responsible for any property damage or missing items within assigned room. Attendees shall agree to leave the rooms in acceptable condition at the time of check-out. Acceptable condition is defined as clean floors, no room damage or loss, and trash and recyclables placed in provided receptacles.
  6. Each attendee shall be provided with one (1) room key and one (1) residential facility entrance key/access card at check-in. If keys are not returned at check-out, attendee will be charged a fee of $72.00 for each lost or unreturned room key and an additional $25.00 will be charged for each entrance key or access card that is lost or not returned. Attendees should report lost keys and cards to Element Staff immediately.
  7. The Element Staff team reserves the right to enter a room at any time to determine compliance with all safety and regulations. A room may also be entered if there is an indication of danger to life, health, or property.

 

Personal Conduct

  1. Attendees shall treat all staff, presenters, speakers, guests and other conference attendees respectfully and politely.
  2. Each attendee will be held accountable for cleaning after themselves.
  3. Be respectful of others, especially during after hours and keep noise to a minimum.
  4. NO smoking within Emory University campus. This includes the use of any tobacco products: smokeless tobacco, clove cigarettes, e-cigarettes, and juuls. It is not permitted on any university-owned or leased property, which includes but is not limited to, buildings, university grounds, parking areas, walkways, recreational and sporting facilities and university-owned vehicles. This prohibition includes smoking in personal vehicles parked on university grounds.
  5. NO solicitation / recruiting of any kind. (Business, Fraternities, Organizational, etc.)
  6. NO inappropriate language of any kind and in any language.
  7. NO alcohol or drinking allowed on the conference site. If you are caught with alcohol, it will be confiscated and will not be returned to you. Element Staff reserves the right to remove you from the conference if deemed necessary.
  8. NO firearms, ammunition, fireworks, explosives, or weapons of any sort are allowed on campus. It will be confiscated and you may be required to leave the premise and the authorities will be notified..
  9. NO physical altercations (fighting, roughhousing, etc.). You will be removed from the conference immediately if caught fighting and the authorities will be notified.
  10. NO harassment of any nature (Sexual, Verbal, Physical, etc.). You will be removed from the conference immediately.

 

PLEASE REPORT ANY ISSUES OR CONCERNS TO ANY ELEMENT STAFF. YOUR IDENTITY WILL BE KEPT CONFIDENTIAL.

 

I, or the undersigned parent/guardian, have read and understood the above Element Conference Housing Rules and Regulations.

 

Student/Participant Signature: 

Date:

Parent/Guardian Signature:   

Date:

(If Participant is under the age of 18)

Leave this empty:

Signature Certificate
Document name: UVSASE ELEMENT II CONFERENCE WAIVER AND RELEASE FORMS
Unique Document ID: e9e1dd8a24c27b55c01cf90d40c72413054400c3
Timestamp Audit
May 3, 2019 9:54 am ESTUVSASE ELEMENT II CONFERENCE WAIVER AND RELEASE FORMS Uploaded by Amy Dao - amy.dao@uvsase.org IP 24.147.71.60