Emergency Medical Release Imagine Tomorrow – Adult Participant In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents including Imagine Tomorrow staff to be an emergency, I authorize WSU and its authorized agents to obtain emergency medical care for me. I will be responsible for any expenses incurred in so doing, including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my health record from providers who treat me and these providers may talk with the program’s staff about my health status. I hold harmless and agree to indemnify Washington State University, its authorized agents, and employees and the staff of Imagine Tomorrow from decisions to seek emergency treatment. ________________________________________________________________ Please complete the following: Imagine Tomorrow Adult Participant: _______________________________ Date of Birth: ______________________________ School Name and State: ___________________________________Advisor Name: ____________________________________ First Last Address: ___________________________________________________________________ City: ______________________________ State: ______________ Zip: ___________ Phone: (____) _________________________ E-mail: ___________________________ Health-Care Providers: Name of participant’s primary doctor(s): _______________________________ Phone: (_____) _____________ Name of dentist(s):________________________________________________ Phone: (_____) ______________ Name of orthodontist(s):____________________________________________ Phone: (__ __) ______________ Additional health care provider(s) name(s) and contact numbers: _____________________________________________________________________________ _____________________________________________________________________________ Medical Insurance Information: This participant is covered by family medical and/or hospital insurance Yes No Primary Insurance Company __________________________________ Policy Number ___________________ Subscriber __________________________ Insurance Company Phone Number (_____) ___________________ Secondary Insurance Company ________________________________ Policy Number ____________________ Subscriber _________________________ Insurance Company Phone Number (_____) ____________________ Name of a person to contact in case of emergency: _____________________________________________________________________________ Phone: (____) _____________________ E-mail: ______________________________ Relationship to participant: _______________________________________________ ________________________________________________________________ I voluntarily sign this authorization. I have read it, and I understand its content and significance. ________________________________________ ______________ ________________________________________ ______________ Witness Signature Date Signature of Imagine Tomorrow Adult Participant Date Mail this completed form to the address below by April 1, 2015. Imagine Tomorrow Washington State University PO Box 645222 Pullman, WA 99164-5222 IMAGINE TOMORROW ACTIVITIES For Participants Age 18 or Older May 29–31, 2015 ASSUMPTION OF RISK I understand that there are risks in participating in recreational activities and educational workshops at the Imagine Tomorrow activities at Washington State University (WSU). In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for all risks that exist, including the risk of death, personal injury, or property loss or damage. I understand that there may also be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks. Risks in participating in the Imagine Tomorrow activities (including touring campus facilities and participating in activities in the Recreation Center), include, but are not limited to: temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, orthopedic damage, head, neck or spinal injuries, loss or use of arms and/or legs, eye damage, disfigurement, burns, drowning or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or from the Imagine Tomorrow activities that cannot be specifically listed. Further, I recognize that the actions of other participants in the activity may cause harm or loss to my person or property. RELEASE OF LIABILITY I release the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses, which I may sustain, as a result of or related to participation in the above event. My participation includes, but is not limited to, travel to and from the event in a private or public vehicle, any activity connected with the event itself, and use of state equipment or facilities for the event whether on or off WSU property. I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and the program sponsors. I sign it freely and voluntarily. DATED THIS _____ DAY of _______, 20____. _________________________________ Name (Printed) _______________________________ Signature _________________________________ Witness’s Name (Printed) ________________________________ Witness’s Signature _________________________________ School Name and State ________________________________ Advisor Name Mail this completed form to the address below by April 1, 2015. Imagine Tomorrow Washington State University PO Box 645222 Pullman, WA 99164-5222 Image and Voice Recording Consent Imagine Tomorrow - Adult Participant _________________________________________________ (print name), hereby grant permission to Washington State University (WSU) to be photographed or otherwise have images or voice recordings made (including but not limited to digital photographs, video or digital moving images and/or voice recordings), for WSU publication or promotional purposes in any medium (including but not limited to print media, newspaper, television, video, motion picture, or Web site on the Internet). I additionally consent to the use of my name and/or interview comments in connection with WSU publication or promotional purposes in print media, newspaper, television, video, motion picture, or Web site on the Internet. I understand that consent to use my likeness or voice recordings is not a condition of participating in the activity and that consent can be refused without any impact in the ability to fully participate in the program. No inducements or promises beyond our acceptance of an opportunity to promote WSU and its programs have been given to the persons signing below. Any other use of images and/or recordings, my name, and/or interview comments requires advance permission. I understand that I can revoke this consent at any time upon notice to WSU, at which time either or both of us will sign a copy of the denial (below) for use of images or voice recordings. I agree to use of digital images or voice recordings as set forth above: ________________________________________________ __________________ Signature of Adult Participant Date ________________________________________________ __________________ _____________________ Signature of Witness (required) Date I do not agree to use of digital images or voice recordings as set forth above: ________________________________________________ __________________ ________________________________________________ __________________ Signature of Adult Participant Signature of Witness (required) _______________________ _______________________ School Name and State ______________________ ________________________ ________________________ Advisor Name (First, Last) Date Date Mail this completed form to the address below by April 1, 2015. Imagine Tomorrow Washington State University PO Box 645222 Pullman, WA 99164-5222
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