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Name of Program Participant: My daughter/son has my permission to attend the to be held on . I hereby waive and release the Texas Alliance for Minorities in Engineering, Inc., TAME, and the and their member organizations and affiliates from all liability and expense, without limitation and without regard to the cause or causes, for actual or alleged claims, damages, and injury. I further agree to hold and TAME harmless, without limitation as to amount, against all liabilities, claims, causes of action and demands for personal injury, property damage, or any claim of whatever nature or kind together with any resulting costs and legal fees, arising out or or caused by any act or omission or alleged act or omission, including a negligent act or omission, of and TAME's agents, servants, or other employees, or occurring on or about or TAME's premises; this agreement to hold harmless specifically and expressly includes liabilities, claims, causes of action, and demands for personal injury, property damage, or any other claim of whatever nature or kind caused by or allegedly caused, in whole or in part, by the negligent or grossly negligent acts or omissions and TAME, or its agents, servants or other employees, without regard to amount. TAME, Inc., is committed to protecting the privacy and safety of all children. There are times when we feel it is appropriate to recognize children and their work in a public forum. Examples of such recognition include publishing a team roster on our web page, exhibiting student art work on the web, displaying photographs of students participating in TAME events on the web or in printed material, and inviting local media to report on events. By signing this Permission Form you are giving TAME, Inc., permission to publish photographs of your child, in print and electronic media including publication on TAME’s internet web site, for any TAME, Inc.-related purposes. This permission is given with no promise or expectation of value in return. In addition, in the case of accident or sudden illness to my child, I authorize the officials of the or TAME to take action deemed necessary to ensure my child's safety or well-being. I understand that, in the case of an emergency, someone will try to contact me or, if I cannot be reached, the other person listed below. Address (Street, City, State, ZIP Code): Parent/Guardian Phone No.: Home Phone Number Work Phone Number Alternate person in case parent can't be reached: Home Phone Number Work Phone Number I, the undersigned, as the parent or legal guardian of (a minor) hereby authorize such diagnostic, medical and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the minor. The attending physician, appropriate staff, and The University of Texas at Austin and its officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnostic, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability. _______________________________ _______________________________ Signature of Parent/Legal Guardian Please print name Date_________________________ MEDICAL INFORMATION RELATED TO MINOR: Allergies: Current Medications: Date of Last Tetanus Booster: Pertinent Medical History:
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