Medical Information Release of Liability Form

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PERSON TO NOTIFY                 RELATION                                           PHONE

Pertinent Medical History, (any drugs, food or environmental allergies, previous illness,

 injury, activity limitations, date of last tetanus shot.

 CONSENT OF MEDICAL

 TREATMENT FOR A MINOR

(Necessary only if applicant is a minor)

As a parent or guardian, I authorize the program director or staff member into whose care I have

entrusted my (son, daughter, ward) to consent to any x-ray examination, anesthetic, medical treatment

and / or hospital care that may be required for him / her.

RELEASE AND WAIVER OF LIABILITY

While participating in activities of an inherent hazardous nature, each participant is assumed to be

voluntarily performing activities for which he / she assumes all risks, consequences, and potential

liability.

The undersigned hereby releases and holds harmless Humboldt State University and its agent or

agents, Humboldt State University Distance Running Camp director and staff, it's employees,

volunteers and any other person, firm or corporation charged or chargeable with responsibility or

liability from any and all claims by reason of accident, illness, injury, death or other consequences

arising resulting from participation in the Humboldt State Distance Running Camp offered under

the auspices of Humboldt State University.

I HAVE CAREFULLY READ THESE AGREEMENTS AND FULLY UNDERSTAND

THEIR CONTENTS.  I AM AWARE THAT THIS IS A RELEASE OF LIABILITY

AND ON BEHALF OF MY / OUR CHILD, I SIGN IT OF MY OWN FREE WILL.

PROOF OF INSURANCE

Medical Insurance Carrier     

POLICY NUMBER

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Signature of Parent or Guardian                                             Date