Adult Participant Information & Waiver Form
The information collected in this form is confidential and will only be shared in a medical emergency.
Thank you for taking the time to fill out the form in its entirety.
Participant’s Full Name:
Address:
City: State: Zip Code:
Home Phone Number: Cell Number:
1
st
Emergency
Contact Name:
Relation to Participant: Home Phone Number:
Cell Phone Number: Work Phone Number:
Place of Employment:
2
nd
Emergency
Contact Name:
Relation to Participant: Home Phone Number:
Cell Phone Number: Work Phone Number:
Place of Employment:
I understand and agree that I am responsible for arranging my own health, accident, and liability insurance, and that no such insurance
is provided by [insert Conference/Organization] and/or Gettysburg College.
I hereby authorize the employees and/or agents of [insert Conference/Organization]
and/or Gettysburg College, at their sole discretion, to secure such medical advice and/or services as may be deemed necessary for my
health and safety, and I agree to accept full financial responsibility for such advice or services.
RELEASE AND INDEMNIFICATION. FOR MYSELF AND ALL THOSE WHO MAY CLAIM THROUGH ME OR IN MY PLACE, AND
IN EXCHANGE FOR AND IN CONSIDERATION OF [insert Conference/Organization]
AND GETTYSBURG COLLEGE PERMITTING ME TO PARTICIPATE IN THIS CONFERENCE AND RELATED ACTIVITIES, I
HEREBY ASSUME ALL THE RISKS OF INJURY ASSOCIATED WITH THIS CONFERENCE AND RELATED ACTIVITIES AND
AGREE TO RELEASE, HOLD HARMLESS, AND INDEMNIFY [insert Conference/
Organization] AND GETTYSBURG COLLEGE, AND THEIR OFFICERS, AGENTS, AND EMPLOYEES FROM ANY AND ALL
LIABILITY, ACTIONS, CAUSES OF ACTION, NEGLIGENCE, CLAIMS OR DEMANDS OF ANY NATURE WHATSOEVER THAT
MAY ARISE BY OR IN CONNECTION WITH MY PARTICIPATION IN THIS CONFERENCE AND RELATED ACTIVITIES.
In signing this document I acknowledge that I am 18 years of age or older, that I have read it, that I understand it, that I have
signed it knowingly and voluntarily, and that I accept and intend to be legally bound by its terms.
Date: Signed:
Name Printed:
Conference Attendee Information
Emergency Contact Information
Waiver/Release Information
This form must be completed, printed, and mailed, emailed (scanned as a PDF file), or faxed to the Conference Director.
