Academic Talent Search - Assumption of Risk and Release of Liability

All information collected in this form will remain confidential.

1Student Information > 2Release Agreement
Student's Full Name Student's Full Name First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of school
Grade in school
Gender

Gender Male Female
Parent's Home Phone Parent's Home Phone - ### - ### ####
Parent's Cell Phone Parent's Cell Phone - ### - ### ####
Emergency Contact Information

This may be updated and completed for every event.
Primary Emergency Contact Name Primary Emergency Contact Name First Last
Primary Emergency Contact Phone Number Primary Emergency Contact Phone Number - ### - ### ####
Secondary Emergency Contact Name Secondary Emergency Contact Name First Last
Secondary Emergency Contact Phone Number Secondary Emergency Contact Phone Number - ### - ### ####
Primary Physician Contact Name Primary Physician Contact Name First Last
Primary Physician Contact Phone Number: Primary Physician Contact Phone Number: - ### - ### ####
Does your student have any allergies that emergency personnel should be aware of when treating your student?

Does your student have any allergies that emergency personnel should be aware of when treating your student? Yes No
Please list those allergies:
Does your student have any medical conditions that emergency personnel should be aware of when treating your student?

Does your student have any medical conditions that emergency personnel should be aware of when treating your student? Yes No
Please list those medical conditions:
Is your student currently taking any medications?

Is your student currently taking any medications? Yes No
Please list those medications:
I release the above information to TRiO Academic Talent Search only to be used in case of an emergency. I understand all above information will remain confidential.
Signature of Parent / Guardian (or student, if over age 18)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Academic Talent Search - Assumption of Risk and Release of Liability

Academic Talent Search - Assumption of Risk and Release of Liability

Emergency Contact Information

I release the above information to TRiO Academic Talent Search only to be used in case of an emergency. I understand all above information will remain confidential.