2008 Pre-Collegiate Summer Seminar in Intelligence
SPONSORED BY THE INTELLIGENCE COMMUNITY CENTER OF ACADEMIC EXCELLENCE AT TRINITY AND A GRANT FROM THE U.S. INTELLIGENCE COMMUNITY
RELEASE OF LIABILITY
STUDENT UNDER AGE 18 (MINOR) ______________________________________________
Name of Student (Please Print)
_____________________________
Date of Birth
a minor for whom I am the parent or legal guardian, has my permission to attend the Summer Seminar in Intelligence at Trinity College from July 14 – July 18, 2008. In case of emergency, Trinity may reach me at: Permanent Address _____________________________________________________________________________
Number and Street Apartment Number ______________________________________________________________________________________________________
City Day Telephone ______________________________
State
Zip Code
Country
Cell Phone _______________________________ E-mail ___________________________________
Evening Telephone ___________________________
Or, if that is not possible, I authorize Trinity College through its employees or agents to determine if treatment can reasonably be provided on site by Trinity staff. I hereby release Trinity College from any liability arising from afore-mentioned treatment, not arising directly from gross negligence of Trinity College and or its officers, agents, employees, successors, and assigns. If on site treatment is not deemed possible, I authorize Trinity College to take my daughter/son to the nearest medical facility for purposes of receiving medical care with the understanding that I will assume any and all responsibility for payment of same. ____________________________________________________________________________________________
Name of Insurance Carrier Policy Number ______________________________________________________________________________________________________ Insurance Carrier Telephone Number
On behalf of myself and my minor daughter/son, _________________________________, I hereby release Trinity College and its officers, agents, employees, and assigns from any and all liability arising out of or in any way related to the Summer Seminar in Intelligence and not arising directly from gross negligence of Trinity College and or its officers, agents, employees, successors, and assigns. Parent/Guardian _________________________________________
(please print name)
Date ___________________________________________________
Signature _______________________________________________