Participant Release Form

HS Conference Participant Info (2024)

Participant Information Form for Business And Ethical Leadership: A Conference For High School Students, on the campus of DePauw University, September 9, 2024.

"*" indicates required fields

I am a...*

Parent/Legal Guardian (for Participant Under 18)

18+ Participant

Chaperone

Participant Name*

First Last

Preferred Name for Participant's Name Tag*

First Last

Email*

School*

Participant Phone Number*

Participant Graduation Year*

2025

2026

2027

2028

Not Applicable (Coach or Chaperone)

Name of Emergency Contact #1*

First Last

Emergency Contact #1 Phone Number*

Name of Emergency Contact #2*

First Last

Emergency Contact #2 Phone Number*

I am covered by personal health insurance*

Yes

No

Medical Treatment in an Emergency*

I consent to medical treatment in the case of an emergency.

Should I require emergency medical treatment, first aid, or transportation to a hospital or medical facility as a result of illness or injury associated with my participation in the Program, I consent to any such treatment, first aid and/or transportation that may be provided, permit Program staff and/or staff of the University Office of Public Safety to provide medically related information from this consent form to treating athletic trainers and/or medical providers, and understand that the Program and DePauw University will not be responsible for any costs associated with any of the foregoing.

I authorize the Program and/or DePauw University to publish or release to the media any pictures or videos of me or my child taken during their time as a participant in the Program for promotional or recognition purposes only.*

Yes

No

If you have any accessibility needs please specify here (ex: access to an elevator, ASL interpreter, etc.)

Please list any dietary restrictions/food allergies:

Please list any allergies or medical conditions you would like us to be aware of:

Shirt Size*

S

M

L

XL

XXL

XXXL

Consent*

By completing this form, I agree to the liability policy outlined below.

By signing below, I signify that I am voluntarily participating in the 2024 Business and Ethical Leadership Conference (the Program) and do so without any duress applied by the Program staff or the University.

I understand that I will be provided with the orientation and training necessary, and as needed, for the safe and responsible participation in the Program.

I, the undersigned, certify that I am choosing to voluntarily and without compulsion participate in the 2024 Business and Ethical Leadership Conference. I recognize and acknowledge that physical injury, accident, illness, death, loss of personal property, or other contingencies may befall me as a participant in the Program. I understand that I am not in any way required to participate in the preceding. In light of the preceding and with sufficient knowledge of my physical and other conditions and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness, and/or injury to person or property which I may, in any way, sustain in connection with participation in the Program. I agree to release the Program and its medical providers, DePauw University, its trustees, officers, employees, agents and volunteers from any and all liabilities, damages, losses and/or causes of action (collectively “Claims”) that I may suffer or have, including without limitation, to my person or property or both, which arise out of, are related to or in connection with, or occur during my participation in or attendance in the Program except to the extent such Claims are caused by the gross negligence or willful misconduct of the staff or the Program and/or agents of DePauw University. I further agree to indemnify and hold harmless the Program and its staff, and DePauw University and its trustees, officers, employees, and volunteers from any and all Claims arising out of, related to, or in connection with the Program that are caused by my negligent or intentionally tortuous acts or omissions.

I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ, FULLY UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, HAVE BEEN ADVISED OF MY RIGHT TO SEEK LEGAL COUNSEL AND THAT I SIGN IT VOLUNTARILY AND WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Signature*

Signatory Email*

I would like to receive further communications from The Janet Prindle Institute for Ethics and DePauw University.