Program Name: Western PA Bruins
Program Coordinator Contact: John Hightower
Location: AJ Palumbo Center
Program Dates: 10/29/18-7/31/19
I give permission for my son/daughter to participate in the program described above. I, for myself, my heirs and legal representatives agree to release, indemnify and hold harmless Duquesne University and all of its officers, administrators, agents, and employees from any and all liability for any injury or loss and all claims, demands and actions at law or in equity that may hereafter at any time be brought by me, or anyone acting on my behalf, for the purpose of enforcing a claim for damages because of any injury (including death) or damage to me resulting from or in any way related to my child’s participation in the aforesaid activity.
I understand that participating in this activity could result in physical and emotional injury, paralysis, death or damage to my child, to property or to others. I hereby acknowledge and agree that in the event of an injury to my child, I will apply my own medical, hospitalization and/or accident insurance toward the payment of any and all expenses incurred and will not look to Duquesne University for the payment of any medical or injury related expenses. I agree that my child may be transported to a local hospital to receive emergency medical treatment by that facility as determined by the Program Coordinator or other Supervising Adults or University personnel. I agree to disclose any form of allergies or other medical condition or physical limitation that might impact participation in the Program.
*Emergency Contact #1
*Relationship to minor
Alt. Phone Contact
*Emergency Contact #2
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