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How many classes do you intend to take?

***The information entered on this screen will be used as Emergency Contact Information

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Parent First Name:

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The following Agreement should be signed by a parent/guardian of the high school student (under age 18) participating in the Dual Enrollment Program. This Agreement will be in affect for the scheduled length of dual enrollment, or until the student is 18 years old.

 

1. Consent and Release Agreement

I (parent/guardian) give my permission for the applicant

to participate in Harrisburg University of Science and Technology’s (HU) Dual Enrollment Program.

This Form covers all student participants in HU’s programs and services delivered by faculty, students, staff, administration and the agencies, companies, and individuals that collaborate with HU.

I understand that my child’s participation in HU’s Dual Enrollment program both at the University’s campuses or at an off-campus location, may involve an element of risk. I agree that in consideration of HU sponsoring this Program and allowing my child’s participation, I forever release, discharge, and covenant not to sue HU, their respective officials, employees, attorneys, insurers, agents, and assigns (collectively referred to as HU) from all liability, claims, demands, actions, and causes of actions arising out of or related to any loss, damage, injury, or disease, including death, that your child, you, or any of your personal property, may sustain. This includes all liability, claims, demands, actions, and causes of actions whether caused by the negligence of HU, or a third party.

You further agree to indemnify and hold harmless HU from any loss, liability, damage, or costs, including court costs and attorney's fees, that you may occur due to your child’s participation in HU’s program, caused by the negligence of HU or otherwise.

This Form continues after your participation in HU’s program has concluded.

By signing this Form, it is your expressed intent that this Form shall bind the members of your family, your heirs, assigns and personal representative, and shall be deemed as a

release, waiver, discharge, and covenant not to sue HU. You further agree that this Form shall be interpreted under the laws of the Commonwealth of Pennsylvania.

By signing this Form, you acknowledge and represent that you have read it, understand it, and sign it voluntarily. You also acknowledge that no oral representations, statements, or inducements, apart from this written form have been made regarding liability and holding HU harmless.

2. Medical Release 

I understand and agree that if representatives of HU believe that my child is experiencing a medical emergency, HU will contact emergency services on my child’s behalf, if the emergency contacts cannot be reached or if the situation requires immediate action. You will be financially responsible for all costs.

3. Photo Release

I give HU permission to use my child’s image or photograph, name, high school affiliation, written and/or recorded statements made in or about the program solely for HU’s non-commercial purposes, including promotion of the program and for use on HU’s website or alternative medial, in any manner, now and in the future.

By Typing your name in the text box, this is your acknowledgement and signature.

 
  
 
  
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