Puente Conference Waiver

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Please carefully complete and digitally sign the following online form for the Transfer Motivational Conference, as specified in your registration confirmation message.

Emergency Information & Contacts

Department & Activity

Department *

Event Name *

Participant

First Name *

Last Name *

Birthdate *

Email Address *

Emergency Contact

In case of emergency, please notify: *

Relationship *

Emergency Contact Address *

Country

Street

City

Region

Postal Code

Primary Phone *

Secondary Phone *

Father's Name or Guardian (if different than above)

Country

Street

City

Region

Postal Code

Home Phone

Work Phone

Mother's Name or Guardian (if different than above)

Country

Street

City

Region

Postal Code

Home Phone

Work Phone

Authorization to Consent to Treatment of Minor

For participants who are considered a minor (under age 18)

(I)(We), the undersigned parent(s)/guardian(s) of:

Student Name

, a minor, do hereby authorize University of California, Davis Health Services or attending medical personnel as agent(s) for the undersigned to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practice Act, California Business and Professions Code §2000 et. seq.; or any X-ray examination, anesthetic, dental or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any dentist licensed under the provisions of the Dental Practice Act, California Business and Professions Code §1600 et. seq.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician or dentist, in the exercise of his/her best judgment, may deem advisable.

This authorization is given pursuant to the provisions of California Family Code §6910. It is understood that every effort will be made by said agent(s) to contact the undersigned prior to exercising this authorization, but no aforementioned medical care shall be withheld if contact cannot be made in a timely manner.

(I)(We) hereby authorize any facility, which has provided medical care to the above-named minor pursuant to the provisions of California Family Code §6910, to surrender physical custody of said minor to the above-named agent(s) upon the completion of medical care. This authorization is given pursuant to California Health and Safety Code §1283.

(I)(We) understand that The Regents of the University of California, its directors, officers, employees, and agents (“The University”) is not responsible for payments incurred due to aforementioned medical care.
These authorizations shall remain effective for 12 months from the date signed below, unless revoked sooner in writing.

Parent/Guardian Full Name *

Parent/Guardian Signature Date *

Physician Information

Physician Name

Physician Address

Country

Street

City

Region

Postal Code

Physician Phone

Insurance

IMPORTANT: IN CASE OF AN EMERGENCY PLEASE BRING A COPY OF YOUR MEDICAL INSURANCE CARD THE DAY OF THE EVENT!

Company Name

Policy Number

Expiration Date

Special Conditions

If the participant has a medical problem, is taking medication or has other information that you would like to discuss in private, please indicate here. We will contact you directly to assure discretion and that this information will be held in confidence.

Other Allergies or Dietary Restrictions

Other

Consent to Record

I give my permission and authorize the University of California ("UC"), to videotape, audiotape, photograph, record, edit or otherwise reproduce my voice, image or likeness, and to use it in various formats and for the purposes within UC's mission of teaching, research, public service and patient care. Distribution methods may include but are not limited to the classroom, television (including UCTV, broadcast, cable, and satellite), the Internet (including webcasts and podcasts), print publications or any other medium now existing or later created. UC retains the right not to use the footage for other than archival purposes.

Any copyright-protected works that I deliberately provide or otherwise include as part of this recording are either my own property or works for which I have the permission of the copyright owner to use in this way.

I grant, assign, and convey to UC all right, title and interest I, my heirs and assigns, may have in and to any recording made under this consent. I understand this total release of rights irrevocably means that UC may, without limitation, exercise all ownership rights including copyrights relating to the recording(s).

I agree to indemnify and hold harmless UC from and against any and all liability, loss, cost, or damage which it may incur as a result of my participation in this recording.

If signed by someone other than the person appearing (such as a parent of a minor child), I warrant that I have the authority to grant this permission on behalf of the person(s) appearing.

Participant Full Name *

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In return for being permitted to participate in the following activity or program ("The Activity"), including any associated use of the premises, facilities, staff, equipment, transportation, and services of the University, I, for myself, heirs, personal representatives, and assigns, do hereby release, waive, discharge, and promise not to sue The Regents of the University of California, its directors, officers, employees, and agents ("The University"), from liability from any and all claims, including the negligence of The University, resulting in personal injury (including death), accidents or illnesses, and property loss, in connection with my participation in the Activity and any use of University premises and facilities.

Description of Activity or Program

Start Date *

End Date *

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

Indemnification and Hold Harmless: Indemnification and Hold Harmless: I also agree to indemnify and hold The University harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees, arising out of my involvement in The Activity, and to reimburse it for any such expenses incurred.

Severability: I further agree that this Waiver of Liability, Assumption of Risk, and Indemnity Agreement is intended to be as broad and inclusive as permitted by law, and that if any portion is held invalid the remaining portions will continue to have full legal force and effect.

Governing Law and Jurisdiction: This Agreement shall be governed by the laws of the State of California, and any disputes arising out of or in connection with this Agreement shall be under the exclusive jurisdiction of the Courts of the State of California.

Acknowledgement 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 confirm that I am signing the agreement freely and voluntarily, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Confirm Participant's Full Name *

Participant Signature Date *

Confirm Participant Date of Birth *