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2017 ECC Medical, Photo Release and Liability Waiver

Please submit a separate form for each family member attending the program.
  • Medical Information (We do not require a signed document from your child's physician.)

  • MEDICAL CONSENT: I understand and agree that Releasees may not have medical personnel available at the location of the Program or off-site Program event. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.
  • This information will be communicated directly with your child's Team Lead. Each Team Lead, is a NC Certified Teacher, trained and qualified to assist your student.
  • Photo Release

  • Queens University Release and Liability Waiver (Electronic Signature Below Required)

  • ELECTIVE PARTICIPATION: I acknowledge that my participation (or my enrollment of my minor child) is elective and voluntary. As a condition of my participation, I hereby grant Queens University of Charlotte the right to use, for promotional purposes only, any photographs of me taken by Queens University of Charlotte, its employees or agents, during my participation in the Program. I further understand and agree that Queens University of Charlotte may use (for marketing purposes) any statements or quotes attributed to me in my evaluation of the Program. INFORMED CONSENT: I have been informed of and I understand the various aspects of the Program. I understand and agree that I/my minor child will engage in activities which may pose a risk of harm. I understand that these activities include but are not limited to: playing, observing or participating in Program activities, or traveling to and from Program events. I further understand and agree that the risks involved in this Program may include, but are not limited to: travel to and from the Program site, including via private vehicle, common carrier, and/or Queens University of Charlotte owned vehicle, injury resulting from game-like activities during the Program as a result of the activity area’s conditions, the acts of third parties or other unknown safety hazards, injuries due to conditions of equipment, unpredictability of weather and conditions, wildlife, first aid operations or procedures of Releasees and/or others, and that there may be other risks not known to me or not reasonably foreseeable at this time. By participating, I/my minor child could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only Queens University of Charlotte’s actions or inactions, but also the actions, inactions, negligence or fault of others, the conditions of equipment used, facility conditions, weather conditions, negligent first aid operations and procedures and I understand that there may be other risks not known to me or not reasonably foreseeable at this time. I further understand and agree that any injury, illness, property damage, disability, or death that I/my minor child may sustain by any means is my sole responsibility except for those occurrences due to Queens University of Charlotte’s gross negligence or intentional acts. RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Queens University of Charlotte, its governing board, directors, officers, employees, agents, volunteers and any students (hereinafter referred to as "Releasees") for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorney fees), arising from any injury, property damage or death that I/my minor child may suffer as a result of my/my minor child’s participation in the Program, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ GROSS NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE PROGRAM, OR ANY ADJUNCT TO THE PROGRAM, OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any way responsible for any injury or damage that I/my minor child sustain as a result of my own negligent acts. ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my/my minor child’s participation in the Program because the Program includes activities, some of which may be dangerous and which may expose me/my minor child to the risk of personal injuries, property damage, or even death. I understand that these potential risks include, but are not limited to: travel to and from the Program site, including via private vehicle, common carrier, and/or Queens University of Charlotte owned vehicle, injury resulting from game-like activities during the Program as a result of the activity area’s conditions, the acts of third parties or other unknown safety hazards, injuries due to conditions of equipment, unpredictability of weather and conditions, wildlife, first aid operations or procedures of Releasees and/or others, and that there may be other risks not known to me or not reasonably foreseeable at this time. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS IF THE RELEASEES, UNLESS THEY ARISE FROM THE RELEASEES’ INTENTIONAL OR GROSSLY NEGLIGENT ACTS, and assume full responsibility for my/my minor child’s participation in the Program. INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys fees), arising from any injury, property damage or death that I/my minor child may suffer as a result of my/my minor child’s participation in the Program, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES OR OTHERWISE, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ GROSS NEGLIGENCE OR INTENTIONAL ACTS. PERSONAL MEDICAL INSURANCE. I agree to purchase and maintain during the term of the Program personal medical insurance for myself/my minor child. I further acknowledge that I am responsible for the cost of any and all medical and health services I/my minor child may require as a result of participating in the Program. CERTIFICATION OF FITNESS TO PARTICIPATE: I attest that I/my minor child am physically and mentally fit to participate in the Program and that I/my minor child do not have any medical record of history that could be aggravated by my/my minor child’s participation in the Program. CHOICE OF LAW: I hereby agree that this Agreement shall be construed in accordance with the laws of the State of North Carolina. SEVERABILITY: If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby. I hereby acknowledge that I have read, understand and will abide by each of the terms and conditions of this Agreement.