This form MUST be signed by a parent or legal guardian of any child participating in specially organized youth programs at Lakehead University. Please bring this completed and signed form to the event on October 17th, 2009 in order for your child to be able to participate.
I have care, custody, and control of the participant, my child, named above in Part 1. I have the authority to grant permission for my child’s participation in the GO ENG GIRL event (hereinafter called the “Event”).
I understand that the University and its representatives will take all reasonable steps to provide individual care and safety for my child, but I also understand and acknowledge that certain risks of injury, loss, damage and harm to my child and his/her property are inherent to participation in any program or activity, and I agree to INDEMNIFY AND SAVE HARMLESS LAKEHEAD UNIVERSITY, its officers, employees, students, agents and volunteers (hereinafter collectively called the “Releasees”) from and against any injury, loss, damage or harm that may befall my child or his/her property as a result of his/her participation in the Event.
I understand as well that I or the adult whom I have designated below must accompany the child named above on the University campus and supervise him or her during all times that the child is not engaged in the activities of the Event.
I agree to HOLD HARMLESS AND INDEMNIFY the Releasees from any and all liability for any damage to the property of, or for personal injury to, any third party resulting from my child’s participation in the Event.
I understand that public news media may be present during the Event to take pictures of and report on the Event.
I declare that I have read and understood, and that I agree to, all the terms of this Registration Form and, in accordance with the said terms, I hereby consent to my child participating fully in the Event.
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Signature of Parent or Guardian
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Printed name of Parent or Guardian
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Name Relationship to Child
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Printed Name of Parent’s or Guardian’ Designated Alternate
Emergency Contact Information
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Phone Number_________________________________________
Date__________________________________________________
Permission is hereby granted to contact my child via mail/email to follow up on their career choice. Yes ____ No _____
Permission is hereby given for any photos of my child to appear in the program brochure or in any other advertising publication by the University. Yes ____ No ______ Note - Red dot to appear on name tag.
Please state any allergies or medical conditions that your child may have:
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The information on this form is collected under the authority of the Lakehead University Act solely for the purposes of running the GO ENG GIRL program and promoting the study of Engineering. Any questions about the collection, use, and disclosure of this information should be directed to Administrative Officer, Faculty of Engineering, Lakehead University, 955 Oliver Road, Thunder Bay, Ontario, Canada P7B 5E1. Telephone: (807) 343-8321.
