Minors on CampusMinors on Campus Click to enlarge Exemption Certificate Parental Permission & Release Form Program Name*select oneAtlanta Saxophone DayBrass DayDouble Reed DayRialto Youth Jazz OrchestraSummer Jazz WorkshopTrumpet & Trombone DayParticipant Name* First Last Participant Date of Birth* MM DD YYYY Parent/Guardian Name* First Last Parent/Guardian Phone Number*Parent/Guardian Email*You will be emailed a copy of your responses from this form to keep with your records. Enter Email Confirm Email Participation Agreement and WaiverAssumption of Risk: I am the parent or legal guardian of the Participant, and allow participation in a Georgia State University Program (the “Program”), facilitated by Georgia State University and its employees and authorized representatives (the “University”). This Program is purely voluntary. As such, I agree to assume all risk on behalf of the Participant. I acknowledge that the Program involves risks such as accidents, illness, injuries, crime, inclement weather, and other hazards arising from a wide variety of events and circumstances that cannot be enumerated. I voluntarily assume all such risk.Waiver and Indemnification: I agree to waive, release, covenant not to sue, forever discharge and hold the University harmless from any and all claims, demands, and causes of action arising out of participation in the Program or related medical care. This waiver also applies to any heirs, executors and assigns. Further, I agree to defend, indemnify and hold the University harmless from any and all claims, demands and causes of action arising out of the Participant’s actions while participating in the Program.Liability Insurance and Exemption from Licensure: The University, as a state entity, is covered by the Tort Claims Act and the State of Georgia Broad Form Insurance, which includes liability insurance. The Program is exempt from the licensing requirements of the Georgia Department of Early Care and Learning because it is administered by a state entity. More information about DECAL is available on its website at www.decal.ga.gov, or by calling 1-888-442-7735.University Limitation of Liability: I understand and acknowledge that the University assumes no responsibility or liability, in whole or in part, for any circumstances beyond the control of the University, including: sickness, disease, accidents, injuries (including death), theft of/damage to property, crime, weather, acts of God; damage or injury of any kind in connection with accommodations, transportation, or other services; or for any additional expense related to any of the foregoing.Deadlines, Refund Policy and Code of Conduct: I agree to abide by all deadlines for payment and/or submission of materials for the Program. I agree that my child may be refused and my fees might not be refunded if I miss these deadlines. I agree that my fees (if applicable) might not be refunded if I withdraw my child from the Program. I acknowledge that my child will be subject to the rules and standards of conduct of the Program and the University System of Georgia. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home. I understand that dismissed Participants are not eligible for a refund of any fees or expenses.Electronic Parent/Guardian Signature*I, the parent/guardian, agree to the terms and conditions above.Parent/Guardian NameDatePhotography Release*I give the University permission to reproduce and use for educational or promotional purposes any and all photographs, videos, movies, or sound recordings taken of Participant during participation in the Program, as well as any written testimonials I or Participant provide regarding the Program. I agree to the photography release. I DO NOT agree to the photography release. Emergency Contact, Medical Information, and Authorization for Medical CareEmergency Contact InformationEmergency Contact Name* First Last Emergency Contact Phone Number*Relationship to Participant*Backup Emergency Contact Name* First Last Backup Emergency Contact Phone Number*Relationship to Participant*Health Insurance Information (if available)Insurance ProviderInsurance Phone NumberPolicy NumberPhysician/Pediatrician PracticePhysician/Pediatrician Phone NumberOptional Insurance Card File Upload(Note: Georgia State University does not offer any form of health, liability, or other types of insurance for participants. If available, please attach a copy of the front and back of your insurance card here.) Drop files here or Emergency Contact, Medical Information, and Authorization for Medical Care ContinuedMedical InformationMedical information we need to know about your child(current conditions, physical limitations, past injuries, etc.)Allergies(medications, stings, foods, iodine, latex, etc.)Medications child is currently taking, dosage, and times takenDoes your child need any accommodations to safely participate in the program?If yes, please explain in the text box that appears below. select oneNo, my child does not need accommodations.Yes, my child needs accommodations.Please explain any accommodations your child needs.Authorization for Program Staff to Administer Medication (if applicable)MedicationDosageInstructions(when to give, whether to take with food, etc.)Special Storage InstructionsI authorize the Program staff to administer my child the above-listed medication. I understand that medication, whether over-the-counter or prescription, must be kept in original containers with original label. When no longer needed, medications shall be returned to me whenever possible. If the medication cannot be returned, it shall be destroyed.Authorization for Medical Treatment I consent to medical and/or surgical care as may become necessary for the Participant’s well-being, should the need arise, and I understand that I will be solely responsible for the the cost. I authorize the University to communicate in emergencies with the person(s) identified in my submission materials. I hold harmless and agree to indemnify the University from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. By checking this form, I agree that all information is accurate and current, that all important information is listed on this form, and to the best of my knowledge, my child is capable of participating safely in the Program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in the above information as soon as possible.Electronic Parent/Guardian Signature*I, the parent/guardian, agree that all information is accurate and current. I certify that all important information is listed on this form.Parent/Guardian NameDate Pick-Up AuthorizationAuthorized Pick-Up Please list any individual other than yourself who is authorized to pick up your child. Authorized individuals must be at least 16 years of age, must pick up the child in person, and may be requested to show identification to program staff. Participant will not be permitted to leave the program with anyone who is not listed below or who does not provide acceptable identification upon request.I authorize the following responsible person(s) to pick up my child from the Program:(To add another authorized person, click the plus button.)Authorized PersonPhone NumberRelationship to Child Please note that your child must be picked up by designated Program times. If an authorized adult is unable to be reached, Program members will contact the local police department as a last resort to take your child home. If you are not at home, your child will be released to the Division of Family and Children Services. Please contact the Program at any time if you need to update this Pick-Up Authorization Form.Authorized Dismissal CHECK HERE ONLY IF your child will be responsible for his/her own transportation (driving or public transportation) to and from the Program, and may sign himself/herself out at the end of the Program. Electronic Parent/Guardian Signature*I, the parent/guardian, certify the above information is correct and give permission to those listed above to pick up my child.Parent/Guardian NameDateBy clicking submit, I agree that all information in this form is correct and current. I certify that I, the parent/guardian, filled out this form.