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Authorization for Medical Treatment, and Waiver and Release of Claims,
In consideration for permission to participate in activities at and to access the property
and facilities of Wright State University, 3640 Colonel Glenn Highway, Dayton, Ohio
45435, I, _______________________________, the parent/guardian of
____________________________ (hereinafter, “Participant”), hereby agree to
indemnify, defend, and hold harmless the State of Ohio, Wright State University, its
Board of Trustees, and its officers, directors, employees, volunteers, agents, affiliates,
and all others who could be held liable (collectively, “Wright State University”) from and
against any and all claims, causes of action, lawsuits, losses, costs, damages, expenses
(including, but not limited to, attorneys' fees) and liabilities due to any injury to or death
of any person, or damage to or loss of any property, arising out of or related to
Participant’s participation in such activities. I also hereby specifically agree to waive and
release any and all claims against Wright State University arising out of or related to any
such activities.
I certify that, to the best of my knowledge and belief, Participant has no known medical
problems or conditions that would prevent him/her from participating in the above-
referenced program or activities at Wright State University. I hereby authorize Wright
State University and/or its authorized agents or emergency medical personnel to furnish
emergency medical services and/or secure emergency medical treatment, including but
not limited to transport and admission to a hospital or other health care facility, for
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Participant as deemed necessary. I acknowledge that Wright State University does not
provide health or accident insurance coverage to participants. I agree to be financially
responsible for any such emergency medical treatment/services and represent that I
have adequate insurance and financial resources to do so. I hereby waive, release,
discharge, and agree to hold harmless Wright State University from and against any and
all liability, loss, damage, and claims of any nature which in any manner arise from or
relate to such services or treatment.
I understand that my child’s participation in the above-referenced program or activities
is performed under this specific understanding. I have read and understand the
foregoing and voluntarily sign this Authorization for Medical Treatment and Waiver and
Release of Claims with full knowledge of its contents and significance.
Signed: Date:
Signed: Date:
Parent/Guardian of Participant