Adult In-Person Program/Camp Informed Consent Waiver

Applicable University Sponsored Program:

Stetson Young Scholars Mock Trial Camp (Week 1)

Stetson Scholars Summit

Stetson Young Scholars Mock Trial Camp (Week 2)

Program Location:

Program Activities Include: classroom activities, outdoor activities, recreational activities, pool and water related activities, team building activities, meals, overnight stays with a roommate, and campus activities

Risks inherent in this Activity include bodily injury or illness due to exposure to infectious diseases, including COVID-19, and: foot travel, climbing stairs, exposure to outdoor elements (sun, heat, weather, wildlife, plants, and insects), loud noises, overnight stay in unfamiliar surroundings, a college campus environment, large groups, local traffic, actions of other participants, unfamiliar foods, pool use an slippery areas, chlorinated water, and potential allergens.

Program Date/Time:

June 8 at 9:00 AM to June 12 at 3:00 PM

June 8 at 9:00 AM to June 10 at 3:00 PM

July 6 at 9:00 AM to July 10 at 3:00 PM

I, the undersigned, state that I am seeking to participate in the above referenced Stetson University, Inc. (hereafter “Stetson”) Sponsored Program (hereafter “Program”). I wish to participate in the above referenced Program on the date(s) indicated above and, in consideration for my participation, I hereby agree as follows:

I acknowledge, understand and appreciate that as part of my participation in the Program there are dangers, hazards and inherent risks to which I may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further realize that participating in the Program may involve risks and dangers, both known and unknown, and have elected to take part in the Program.

I hereby release Stetson, its Board of Trustees, Administration, Faculty, Staff, Student Leaders, the Program Staff, and all other officers, directors, employees, volunteers and agents from any and all liability as to any right of action that may accrue to my heirs or representatives for any injury or loss that I may suffer while training, preparing, and/or participating in the Program. This agreement is binding on my heirs and assigns.

I give my permission for and grant Stetson the irrevocable right to interview me and/or record his/her participation in the Program and appearance on video tape, audio tape, film, photograph or any other media, whether now known or hereafter existing (the “Recordings”), use my name, likeness, and/or voice in connection with the Recordings and in keeping with Stetson policies and mission statement, use, reproduce, distribute, publicly display and/or publicly perform, either electronically or by any other media, whether now known or hereafter existing, and to allow others to do the same, my name, likeness or voice, the Recordings, in whole or in part worldwide, without restrictions or limitations, in perpetuity, for any purpose related to Stetson’s mission, including without limitation, promotional or educational. I agree to make no accounting, monetary or other claim against Stetson for use of my name, likeness, voice, or the Recordings.

I furthermore release, indemnify and hold harmless Stetson from and against any and all liability, actions, debts, claims and demands of every kind whatsoever, specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim, loss or liability for injury to person or property that I may suffer, for which I may be liable to any other person, that may or does arise out of my participation in the Program.

This RELEASE shall be governed by and construed under the laws of Florida. I agree that any legal action or proceeding relating to this RELEASE, or arising out of any injury, death, damage or loss as a result of my participation in any part of the Program, shall be brought only in Volusia County, Florida.

This RELEASE contains the entire agreement between the parties to this agreement and the terms of this RELEASE are contractual and not a mere recital. The information I have provided is disclosed accurately and truthfully. I have been given ample opportunity to read this document and I understand and agree to all of its terms and conditions. I understand that I am giving up substantial rights (including my right to sue), and acknowledge that I am signing this document freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability to the greatest extent allowed by law. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

Participant First Name:

Participant Last Name:

Participant Date of Birth:

Participant Signature:

Current Date:

Participant Address:

Country

Street

City

Region

Postal Code

Adult In-Person Program Consent for Emergency Medical Treatment

Emergency Contact #1 Name

Emergency Contact #1 Phone Number

Emergency Contact #2 Name

Emergency Contact #2 Phone Number

Health Insurance

Health Insurance Carrier

Policy Number

Plan Number

Name of Family Physician

Family Physician Phone Number

Health History

Please check and provide approximate dates that the Participant suffered from allergies and other conditions listed below:

Other:

Do you have any medical issues the Program staff should be aware of?

Yes

No

If yes, please explain:

Are there any activities from which you should be restricted?

Yes

No

If yes, please explain:

Does you have any special dietary restrictions?

Yes

No

If yes, please explain:

Does you wear any medical appliances (glasses, orthodonture, etc.)?

Yes

No

If yes, please explain:

Will you need to take any medication during the program?

Yes

No

If yes, please list the specific prescription or over-the-counter medications below, reasons for medication, and daily dosage. If any medications change prior to arriving at the Program, please provide an updated list upon arrival.

If at all possible, medication should be administered at home. Medications will be allowed at the Program only when failure to take such medicine would jeopardize the health of a participant and they would not be able to attend the Program if the medicine were not made available.

I, the undersigned, state that I am seeking to participate in the above referenced Stetson University, Inc. (hereafter “Stetson”) Program (hereafter “Program”). I wish to participate in the above referenced Program on the date(s) indicated above and, in consideration for my participation, I hereby agree as follows:

I acknowledge that I must be able to self-administer all prescription and non-prescription medications if they are needed during the Program. The Program does not assist participants in taking their prescription or non-prescription medications unless it is necessary for emergency treatment, nor does the Program remind participants to do so.

I acknowledge that all prescription medications, including medications for conditions such as food, drug, or insect allergies; diabetes; asthma; or epilepsy may be brought to the Program under the condition that I can self-manage care and delivery of medication. All medications (prescription and over-the-counter) must be stored in the original product packaging and clearly labeled with my name. Prescription medication(s) must also include a label with the medication’s name and dosage instructions, as well as the prescribing physician’s name and telephone number.

I acknowledge that I am required to disclose my intention to bring medications to the Program, especially to treat potentially life-threatening conditions (i.e. inhalers, EPI-pens, insulin injections). Upon arrival to the Program, I must meet with a member of the Program staff at registration to review my medication issues. I understand that it is NOT permissible for me to share any medications with any other participants.

I acknowledge the need for emergency medication may require that a Program participant carry the medication on their person or that it be easily accessed (i.e. inhalers, EPI-pens, insulin injections). Program staff will NOT purchase medications of any type (prescription or over-the-counter) for Program participants of any age.

I hereby authorize the Program Staff or other licensed health care practitioners, acting within the scope of his or her practice under State law, to provide medical care that includes routine diagnostic procedures (e.g., x-rays, blood and urine tests) and medical treatment as necessary. I understand that the consent and authorization herein granted does not include major surgical procedures and is valid only during the Program. In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact my emergency contacts. However, in the event of an emergency and if they cannot be reached, I give my consent for Stetson Program staff or other licensed health care practitioners to perform any necessary emergency treatment.

I acknowledge that it is my responsibility to provide medical coverage, and/or provide any payments for medical costs that may arise as a result of injuries related to Program activities, including those costs that may exceed or be excluded from a Stetson accident insurance policy if applicable. I hereby consent and give my permission to be treated for emergency medical care and first aid by a medical facility and/or clinic personnel at their discretion, and release them from liability for such decisions. I certify that I have completed the medical information on Page 1 of this form as well.

I furthermore release, indemnify and hold harmless Stetson from and against any and all liability, actions, debts, claims and demands of every kind whatsoever, specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim, loss or liability for injury to person or property that I may suffer, for which I may be liable to any other person, that may or does arise out of my participation in the Program.

This consent shall be governed by and construed under the laws of Florida. I agree that any legal action or proceeding relating to this RELEASE, or arising out of any injury, death, damage or loss as a result of my participation in any part of the Program, shall be brought only in Volusia County, Florida.

Participant Signature:

Current Date:

Acknowledgement of the Code of Community Standards

I acknowledge and understand that I am expected to adhere to the Stetson University Code of Community Standards policies while participating in and on campus for summer orientation at Stetson University. I understand that failure to abide by the policies listed in the Code of Community Standards could result in a hearing with the Office of Community Standards.

Code of Community Standards: https://www.stetson.edu/administration/community-standards/code-of-community-standards.php

Participant Signature: