GEORGIA STATE UNIVERSITY

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1 PARTICIPATION AGREEMENT AND WAIVER Assumption of Risk: I am the parent or legal guardian of the Participant, and allow participation in a Georgia State University Program (the Program ), facilitated by Georgia State University and its employees and authorized represenatives (the University ). This Program is purely voluntary. As such, I agree to assume all risk on behalf of the Participant. I acknowledge that the Program involves risks such as accidents, illness, injuries, crime, inclement weather, and other hazards arising from a wide variety of events and circumstances that cannot be enumerated. I voluntarily assume all such risk. Waiver and Indemnification: I agree to waive, release, covenant not to sue, forever discharge and hold the University harmless from any and all claims, demands, and causes of action arising out of participation in the Program or related medical care. This waiver also applies to any heirs, executors and assigns. Further, I agree to defend, indemnify and hold the University harmless from any and all claims, demands and causes of action arising out of the Participant s actions while participating in the Program. University Limitation of Liability: I understand and acknowledge that the University assumes no responsibility or liability, in whole or in part, for any circumstances beyond the control of the University, including: sickness, disease, accidents, injuries (including death), theft of/damage to property, crime, weather, acts of God; damage or injury of any kind in connection with accommodations, transportation, or other services; or for any additional expense related to any of the foregoing. Deadlines, Refund Policy and Code of Conduct: I agree to abide by all deadlines for payment and/or submission of materials for the Program. I agree that my child may be refused and my fees might not be refunded if I miss these deadlines. I agree that my fees (if applicable) might not be refunded if I withdraw my child from the Program. I acknowledge 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.

2 Optional Photography Release: I give the University permission to reproduce and use for educational or promotional purposes any and all photographs, videos, movies, or sound recordings taken of Participant during participation in the Program, as well as any written testimonials I or Participant provide regarding the Program. INITIAL HERE ONLY IF YOU DO NOT AGREE TO PHOTOGRAPHY RELEASE: Agreement: I agree to the terms and conditions of this document.

3 EMERGENCY CONTACT, MEDICAL INFORMATION AND AUTHORIZATION FOR MEDICAL CARE Emergency Contact Information Emergency contact name and phone number: Relationship to Participant: Backup emergency contact name and phone number: Relationship to Participant: Health Insurance Information (if available) Insurance Provider: Insurance Phone Number: Policy Number: Physician/Pediatrician Practice: Phone Number: (Note: Georgia State University does not offer any form of health, liability, or other types of insurance for participants. If available, please attach a copy of the front and back of your insurance card with this form.) Medical Information 1. Medical information we need to know about your child (current conditions, physical limitations, past injuries, etc.):

4 2. Allergies (medications, stings, foods, iodine, latex, etc.): 3. Medications child is currently taking, dosage, and times taken: 4. Does your child need any accommodations to safely participate in the program? If yes, please explain. Authorization for Program Staff to Administer Medication (if applicable) Medication: Dosage: Instructions (when to give, whether to take with food, etc.): Special Storage Instructions: I authorize the Program staff to administer my child the above-listed medication. I understand that medication, whether over-the-counter or prescription, must be kept in original containers with original label. When no longer needed, medications shall be returned to me whenever possible. If the medication cannot be returned, it shall be destroyed. Authorization for Medical Treatment I consent to medical and/or surgical care as may become necessary for the Participant s well-being, should the need arise, and I understand that I will be solely responsible for the the cost. I authorize the University to communicate in emergencies with the person(s) identified in my submission materials. I hold harmless and agree to indemnify the University from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. By signing this form, I agree that all information is accurate and current, that all important 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 as soon as possible.

5 PICK- UP AUTHORIZATION Authorized Pick-Up Please list any individual other than yourself who is authorized to pick up your child. Authorized individuals must be at least 16 years of age, must pick up the child in person, and may be requested to show identification to program staff. Participant will not be permitted to leave the program with anyone who is not listed below or who does not provide acceptable identification upon request. I authorize the following responsible person(s) to pick up my child from the Program (you may write additional names and information on the back of this Pick-Up Authorization Form as needed): Authorized Person Phone Number Relationship to Child Please note that your child must be picked up by designated Program 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 and Children Services. Please contact the Program at any time if you need to update this Pick-Up Authorization Form. Authorized Dismissal: INITIAL HERE ONLY IF your child will be responsible for his/her own transportation (driving or public transportation) to and from the Program, and may sign himself/herself out at the end of the Program.