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UNIVERSITY OF UTAH MINOR PARTICIPANT INFORMED CONSENT & (University of Utah)

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UNIVERSITY OF UTAH
IMPORTANT: THIS IS A LEGAL DOCUMENT,
PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE SIGNING.
MINOR PARTICIPANT INFORMED CONSENT & PARENT/GUARDIAN CONSENT
TO TREATMENT, WAIVER AND RELEASE FOR U OF U EVENT OR ACTIVITY
This Agreement must be completed by the Participant and by Parent(s)/Legal Guardian in order
to participate in the activities associated with this program.
Participant (print full name): ________________________________________________
Program and/or Course (Specify if online):
Date(s) of Program/Course: ________________________________________________
MINOR PARTICIPANT INFORMED CONSENT
I, the undersigned, am the Participant named above. I am familiar with the curriculum and the activities
which take place in the above named Program at the University of Utah, the partnership location, or if the
course is taught in an online format, at a location chosen by the Participant/Guardian (the “Program”). I
understand that my participation can include foreseeable and unforeseeable risks and other hazardous
activities inherent in the program, which may expose me to illness, injury or death. Knowing of these
risks, I freely and voluntarily participate in the Program.
I am also familiar with the rules of conduct and University policies relating to this Program. I agree to
abide by the all of the operating procedures, including, but not limited to, safety procedures outlined by
the Program instructor, plus any directions given to me by an authorized University employee during the
course of the Program.
___________________________________
(Signature of Minor Participant age 12-17)
PARENT/GUARDIAN CONSENT TO TREATMENT, WAIVER AND RELEASE
I________________________________ am the parent/guardian of the above named Participant who is
under 18 years of age. I am familiar with the curriculum and the activities which take place in the above
named Program and hereby give consent for the Participant to participate in the Program. I understand
that participation in the Program can include foreseeable and unforeseeable risks and other hazardous
activities inherent in the program, which may expose the participant to illness, injury or death.
I acknowledge that if the course is taught in an online format and at a location chosen by me, I am
responsible for the supervision of the Participant during his/her participation in the Program.
I state that Participant is free from any health problems, including but not limited to heart or respiratory
problems that could prevent Participant from safely participating in any of the activities.
I hereby give my express consent in the event of injury at the University of Utah or business
partner location(s) for the University to obtain for the Participant any necessary emergency aid,
anesthesia and / or operation, if in the opinion of the attending physician, such treatment is
necessary.
2
I certify that participant has medical insurance (provide insurance information below) and otherwise agree
to be personally responsible for costs of any emergency or other medical care that Participant receives. I
agree to release, waive, covenant not to sue, and hold harmless the University, and all of their officers,
employees and agents (collectively the "Releasees") from the cost of any medical care that Participant
receives as a result of participation in the Program.
I understand and acknowledge that the University of Utah is not an insurer of Participant’s behavior,
actions or participation in the Program and that the University assumes no liability whatsoever for
personal injuries or property damages to Participant or to third persons arising out of Participant’s
participation in the Program activities.
I agree to release, waive, covenant not to sue, indemnify and hold harmless the Releasees from any and
all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss,
damage, injury, illness, attorney’s fees or harm of any kind or nature to me arising out of Participant’s
participation in the Program and excepting only such loss, damage or injury as may be caused by the sole
negligence of any Releasee. This release extends to any claim made by parents or guardians or their
assigns arising from or in any way connected with the aforementioned activities.
I agree that the site of any lawsuit arising out of or related to participation in the Program shall be Utah
and that this Agreement will be governed by and construed in accordance with the laws of the state of
Utah, without application of any principles of choice of law.
I shall pay any attorney fees or costs incurred by the University in enforcing this Agreement.
If any portion of this Agreement is held to be invalid by a court of law, then it is agreed and intended that
all the remainder shall, notwithstanding, continue in full force and effect.
I acknowledge that I am at least eighteen (18) years of age and I have read this document in its entirety
and fully understand the terms of this Agreement.
*The University of Utah is committed to protecting minors participating in University programs. If you,
as a parent/guardian, have concerns about any misconduct in connection with the above named
Event/Program, please contact the University’s Office of Equal Opportunity and Affirmative Action at
(801) 581-8365.
______________________________________________ ___________________
Signature of Legal Guardian and/or Parent of Participant Date
______________________________________________
Emergency Contact Name and Relationship to Participant
______________________
Phone Number
Participant has been advised to maintain health & accident insurance to cover the costs of treatment in
the event of any injury or illness.
Participant's Insurance I.D. number and insurance carrier, carrier address and phone number:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Updated 4/28/20 Online and Live Classes Waiver
Updated 04/06/2021
COVID Protocol and Sick Policy Expectations – Summer 2021
Program/Activity/Camp Name: _________________________________________________
Participant Name: ____________________________________________________________
Parent/Guardian Name: ________________________________________________________
Program Sick Policy
The Program has established a sick policy for all Participants and Parents/Guardians. It is the responsibility
of the Parent/Legal Guardian and the Participant to review and know the policy.
Program COVID Protocols
The Program has established protocols to reduce the spread of COVID-19. It is the responsibility of the
Parent/Legal Guardian and the Participant to know and follow all protocols and expectations related to
COVID-19 protocols.
Expectations of parent/guardian to support their child’s participation:
● My child will not attend if experiencing any of the following symptoms:
○ A fever of 100.4°F or higher (any time within the last 24 hours)
○ A new or worsening cough
○ A sore throat
○ Tightness in the chest or difficulty breathing
○ Muscle aches, headache, or chills
○ Change in taste or smell
○ Nausea, vomiting, or diarrhea
● My child will not attend if they or anyone in the household been ordered to quarantine or isolate
by the Health Department due to COVID-19
● I will follow health screening protocols as directed by the program administrators
● I will notify the program director should my child test positive for COVID-19 at any time during
the program
● I will promptly pick up my child if they show symptoms of illness during camp and I am contacted
by program staff
Expectations of participant:
• I will follow all COVID protocols:
o Follow proper hand hygiene and sick etiquette
o Maintain physical distancing
• I will notify a staff member if I start to feel ill while at class or camp
• I am expected to be respectful to the staff and other participants
Updated 04/06/2021
What are the consequences if I do not follow the rules and policies of the program?
• Students will be asked to return home if rules and policies are not followed.
The following may result in being dismissed from the program:
• Students will be dismissed from the program if there are 2 incidents of breaking the rules.
Liability Waiver COVID Language
“The University of Utah is taking precautions to protect participants from exposure to Covid-19, and
following CDC recommendations for physical distancing and hand hygiene, in accordance with the
University In-Person Youth Programming Guidance. The University, however, cannot guarantee that
exposure will not occur. I acknowledge that under Utah law, the University of Utah is not liable for any
damages or injury resulting from exposure of an individual to COVID-19 on the University premises, or
during any activity managed by the University.”
______________________________________________ ___________________
Signature of Legal Guardian and/or Parent of Participant Date
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UNIVERSITY OF UTAH MINOR PARTICIPANT INFORMED CONSENT & (University of Utah)

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Completed 5 May 2022

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