PARENTAL RELEASE and INDEMNIFICATION FORM for
“Take Our Kids To Work” Program: Wednesday November 1, 2017
(Return to Environmental Health & Safety, ASAP for tours, & before Friday October 27, 2017)
email: ehs@uoguelph.ca
fax: 519-824-0364 mail: EHS, Alexander Hall, Room 162
Parent/Guardian Name: _____________________________________________________
Address: ____
_________________________________________________
Department
: _____________________________________________________
University Extension: ________________
I/We ________________________ and __________________________ is/are the legal guardian or
custodial parent of _______________________________, a minor child (who attends grade 9 at: ___________________
school). Such minor child shall hereinafter be referred to as the participant”.
I
am aware that as a result of participating in the “Take Our Kids to Work Program, (herein referred to as the
“Program”) the participant may be exposed to certain risks and dangers inherent in the workplace. In consideration of
the University of Guelph approving the participation of the participant in the Program,
I/We _________________________ and _____________________ the parents/guardians of the participant agree, for
ourselves, our heirs, next of kin, executors, administrators and assigns to hereby release and forever discharge the
University of Guelph, its officers, directors, servants, employees and agents from any and all actions, claims and
demands for damages, loss and injury, howsoever arising which now or may hereafter be sustained by me/us or the
participant or both arising out of or in consequence of the attendance or participation by the participant in the Program.
I also acknowledge the University of Guelph does not carry medical, personal health, dental, accident and/or personal
property insurance coverage with respect to the participant.
For the same consideration, I/We_________________________ and _________________________, the
parents/guardians of the participant agree to indemnify the University of Guelph, its officers, directors, servants,
employees and agents from any claims or demands which might be made against the University of Guelph, its officers,
directors, servants, employees and agents arising out of or in consequence of the attendance or participation by the
participant in the Program.
I/We declare that we have read and have understood the above Parental Release and Indemnification Form for
“Take Our Kids to Work Program” in its entirety and hereby agree to be bound by the terms and conditions. I/We
are aware that by signing this agreement, we are waiving certain legal rights which I/we, my/our heirs, next of kin,
executor(s), administrator(s) and personal representative(s) may have against the University of Guelph, its
officers, directors, servants, employees and agents. I/We accept the risks associated with my child’s
participation in the job shadowing noted below.
Signatur
e: Date:
Parent or Guardian (Print and Sign)
Department where child will be participating/ Campus/ Station Bldg/Room Number
Job Title to be Shadowed____________________ Person Providing Supervision__________________ Extension_____
(P
lease print)
Mandatory Departmental Orientation will be Prov
ided ____ (check to confirm)
Planned activities/tour #: (a.m.)
and/or
Activities/tour #, if desired (p.m.)
____________________________________________________________________________________________
Approving Dean/Designate or Director/Designate (Print and Sign) Extension
Date
AM Tours
PM Tours
PM Tours
click to sign
signature
click to edit
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