Honors Symposium Medical and Liability Release Form

Student's General Information

Fields marked with an asterisk (*) are required.

Last Name

First Name

Middle Name

Sex

Birthdate

Student Phone Number

Student Email Address

Mailing Address

Country

Street

City

Region

Postal Code

Emergency Contact Information

Primary Guardian's Information

Relationship

First Name

Last Name

Phone

Email

Secondary Guardian's Information

Relationship

First Name

Last Name

Phone

Email

Emergency Contact (If above are unreachable)

Relation

First Name

Last Name

Phone

Email

Insurance Information

Name of Medical Insurance Company

Policy Holder

Policy #

Please provide a copy of your medical ID card

Student's Health History

Types of allergies/dietary restrictions and usual treatment for a reaction (If any)

List any medical/psychological/social problems with Date of Diagnosis/Onset

Recent Surgeries
Type of Surgery - Hospital - Year

Recent (or significant) hospitalizations or ER visits
Reason for hospitalization - Hospital - Year

List all medications currently prescribed
Name of medication - Strength (Dosage) - Frequency Taken - Reason for Taking

Assumption of Risk, Release of Liability, and Indemnity Agreement

I understand and acknowledge that participation in Honors Symposium involves certain inherent risks, including but not limited to risks associated with physical activity, travel, housing, social interaction, and educational programing. I, on behalf of myself and my child, voluntarily assume all risks.

In consideration of Harding University allowing my child to participate in Honors Symposium, I hereby release and discharge Harding University, its trustees, officers, employees, agents, and volunteers ("Released Parties") from any and all claims, liabilities, demands, actions, or causes of action arising out of, or relating to any injury, illness, loss or damage that may occur during or as a result of my child's participation in the program, whether caused by negligence or otherwise.

I further agree to indemnify and hold harmless the Released Parties from any claims brought by, or on behalf of my child, or any third party arising from, or in connection with my child's participation. This agreement shall be governed by the laws of the State of Arkansas, and any disputes shall be brought exclusively in courts located in White County, Arkansas.

Acknowledgement and Signature

I consent to the above-named student to participate in Harding’s Honors Symposium, and I confirm that I have read, understood, and voluntarily agree to the terms of this Medical and Liability Release. I certify that I am legally authorized to execute this release on behalf of the above-named minor.

I further authorize the Honors Symposium personnel to sign documents permitting the performance of medical assistance as deemed necessary by legally licensed medical personnel at the time of illness or injury to the above student and will accept the financial responsibility for said medical assistance.

Signature of Parent