Music for Minors: Parental Consent, Emergency Contact, and Legal Release

Participant Information

Participant First Name

Participant Middle Name

Participant Last Name

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Participant Email Address (optional)

Participant Phone Number (optional)

Current School

Grade Level

Please select your organization or activity:

Please specify:

Date of Activity/Visit

Parental Consent, Emergency Contact, and Legal Release

I. I give permission for my child/dependent to participate in the Activity.

II. I understand that there are risks to which my child/dependent may be exposed by participating in the Activity. Such risks include physical and emotional injury, illness, potential exposure to viruses (such as COVID 19) and bacteria, hospitalization, and death or damage to my child/dependent, to property, or to others.

III. I agree to disclose any form of allergies or other medical condition or physical limitation that might impact my child/dependent’s participation in the Activity.

IV. I assure the University that, to the best of my knowledge, information, and belief, my child/dependent is able to engage in the Activity without any undue or unusual risk to my child/dependent or others.

V. I acknowledge and agree that Duquesne University takes seriously the health and safety of the University community, including visitors, and has made and may continue to make operational adjustments related to public health concerns such as the COVID-19 pandemic. I understand and agree that I (and my child/children) am responsible for participating in these efforts and for complying with all University health and safety rules, and may be asked to leave campus if we fail to follow such rules. I understand and agree that while these rules are intended to mitigate the health and safety risks, the University cannot guarantee that participants in the Activity will not contract transmittable diseases such as COVID-19.

VI. In agreeing to allow my child/dependent to participate in the Activity, I assume the risk of my child/dependent’s exposure to COVID-19, which risk is being mitigated by the University’s operational adjustments and participant compliance with health and safety rules, but which risk cannot be totally eliminated. In the event of any online instruction: I confirm that for the duration of each online lesson or class, I am able to see, hear, and direct/supervise the interactions with my child/dependent and their instructor.

VII. I acknowledge and agree that in the event of a medical issue or an injury to my child/dependent related to or arising out of the Activity including but not limited to those described above, I will apply my own medical, hospitalization and/or accident insurance toward the payment of any and all expenses incurred and will not look to Duquesne University for the payment of any medical or injury related expenses. I further agree that my child/dependent may be transported to a local hospital to receive emergency medical treatment by that facility as determined by the Program Coordinator or other Supervising Adults or University personnel.

VIII. I appreciate the character of the risk taken and voluntarily assume all risk of harm.

IX. Therefore, I agree to assume and take on myself all of the risks and responsibilities in any way associated with my child/dependent’s participation in the Activity. I release, acquit and forever discharge the University and its employees, agents, members, officers, directors, students and representatives (the “University Releasees” in their official and individual capacities) from any and all liability whatsoever for any and all damages, losses or injuries (including death, mental anguish or emotional distress) to persons and/or property, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses (including hospital and medical expenses or deductibles) and/or attorney’s fees, that occur during, result from, arise out of or relate to my child/dependent’s participation in the Activity.

X. I recognize that this Release means I am giving up, among other things, rights to sue the University Releasees for injuries, damages or losses I may incur. I also understand, and agree, that this Release binds my heirs, executors, administrators, successors, assigns and personal representatives, as well as myself.

XI. I agree that this Agreement is governed by the laws of the Commonwealth of Pennsylvania.

XII. I have read this entire document. I fully understand its terms and provisions, I agree to be bound by it, and I have signed it knowingly and voluntarily.

I HAVE READ THE ABOVE RELEASE AND HOLD HARMLESS AGREEMENT, I UNDERSTAND THE SAME, AND I AGREE TO BE LEGALLY BOUND BY ALL OF THE TERMS STATED THEREIN.

YES

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Additional Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Emergency Contact's Relationship to Participant

Image Consent and Release (optional)

I hereby give to Duquesne University of the Holy Spirit (Duquesne), along with its agents, employees, legal representatives, and assigns the right and license to use my daughter’s/son’s name, image, likeness, and comments in Duquesne materials for internal and external audiences. These materials include, but are not limited to advertisements, brochures, viewbooks, news releases, magazines, newspapers, newsletters, videos, websites, and social media. Participant’s images may be used in all marketing, including university-wide communication for all audiences and across all Duquesne schools and programs.

It is hereby stipulated and agreed that such production and use will not violate my child’s rights, and I, for myself, my heirs, executors, administrators, and assigns, hereby release and discharge Duquesne and its agents and employees from any and all claims, demands, and/or causes of action of whatever kind, for its actions taken pursuant to the authority granted herein.

Further, it is hereby stipulated and agreed that I will receive no compensation for the use of my daughter’s/son’s name, likeness, or comments, and Duquesne University will incur no liability for payment of compensation to me nor any person or organization as a result of its production and use thereof.

I have read this Image Consent and Release, understand the contents, and agree to the terms and conditions.

Yes

No

Upon submission, you will be directed to a confirmation page.

NOTICE: Duquesne University will not share any of your personal data, but may contact you about events and opportunities on campus and online. You may opt out at any time.