CONSENT FOR MINOR’S PRESENCE IN LABORATORY
I, the undersigned parent/legal guardian of
________________ [name of minor] who was born on
_______________, understand and consent to the following:
I understand that my child has been offered the opportunity to participate in a project in a laboratory or other
hazardous area at Georgia Regents University (GRU) and will be assigned for the period from
_____________ to
_____________ under the supervision of:
________________________________
Head of Laboratory
______________________________
Head of Department
I further understand that laboratories are specialized environments involving the use of scientific instrumentation
and hazardous chemicals and biological materials, which even under ideal laboratory conditions involve risk
and, despite the proper use of substances and adherence to safety procedures, may result in personal injury.
The hazardous chemicals and/or biohazardous materials that may be in this laboratory and to which my child
may be exposed include ( check here if additional sheet is attached):
Hazardous materials*
(Biological and Chemical)
Possible risks from exposure
*This list is not intended to be exhaustive.
My child has no allergies or other physical, mental, or emotional conditions that might limit his or her ability to
safely participate in the activities of this laboratory. I understand that my child will be required to attend a
laboratory safety instruction course, take and successfully complete on-line training courses, and will be taught
and supervised in the proper handling of laboratory instrumentation and equipment, chemicals and biological
materials.
I give my permission to GRU, its physicians, members of its faculty, agents and employees to provide all
emergency care and treatments as in their judgment may be deemed necessary or advisable in the event that
my child should require emergency care as the result of his/her presence at GRU. I assume the responsibility
for the payment of all such emergency care and treatment. I also assume responsibility for the payment of all
subsequent treatment and care that my child may require.
insurance information below:
I have listed emergency contact and medical
Emergency Contact Information
Primary
Secondary
Name(s):
__________________________
Name(s)
_____________________________
Relation to Student:
__________________
Relation to Student
____________________
Daytime phone:
_____________________
Daytime Phone
_______________________
Evening phone
______________________
Evening Phone
________________________
Medical Insurance Information:
Insurance Carrier:
______________________
Carrier Group Number
_________________
Policy Holder's Name
___________________
Policy Holder's ID#:
___________________
If applicable, Insurance Carrier pre-certification telephone number
____________________________
Address for claim submission
__________________________________________________________
In consideration of GRU permitting my child to participate in a project in a laboratory, I hereby release, indemnify
and hold harmless the Board of Regents of the University System of Georgia, GRU, and their members,
employees, agents and authorized representatives from all claims, demands, rights, causes of action, suits,
liabilities, losses, damages, costs and expenses (including attorney fees and court costs) arising out of or
resulting from the presence of my child in the above referenced laboratory.
Knowing and understanding the circumstances and the risks described above, I consent to allow my child to be
present and participate in a project in the above-referenced GRU laboratory.
________________________________
Parent/legal guardian (printed name)
________________________________
Parent/legal guardian’s signature
Date
________________________________
Witness (printed name)
________________________________
Witness’ signature
Please return completed form to:
Date
Walter Loring, MS, CHP
Director/Interim AVP Environmental Health and Safety
Georgia Regents University
Environmental Health and Safety Division
1405 Goss Lane, Bldg. CI-1001
Augusta, GA 30912
Fax: 706-721-7499
Your child cannot participate in any laboratory activities until this form is signed and returned and final
approval is granted by the Environmental Health and Safety Division.
Potential Hazard and Risk Information Sheet
Potential Hazards
Animals
Chemicals
General Information
Research animals represent a variety of species, temperaments, and health conditions. They can cause physical injuries;
transmit zoonotic diseases (diseases passed from animals to humans); or be a source of allergens or toxins.
A chemical is a refined compound that may be in the form of a solid, liquid or gas. Potential injuries include burns of the skin
or eyes; respiratory problems, allergic reactions; irritation of skin, eyes, and mucous membranes; and illness. Based on their
specific effect, chemicals may be classified in one or more of these categories:

Allergens-cause allergic reactions

Carcinogens-produce cancer

Teratogen-affect male and female reproductive systems; may cause birth defects in the developing fetus.

Flammables-burn or explode

Reactives-react explosively

Corrosives-cause tissue damage upon contact including inhalation

Toxins-cause illness or death upon exposure. (Neurotoxins specifically affect the nervous system).
Equipment and
Potential hazards from mechanical or electrical equipment include loud noises, very high or very low temperatures, electrical
Instrumentation
shock, and pinching/crushing injuries.
Gases
Gases may be toxic, corrosive, or flammable. They may cause eye and skin irritations, respiratory problems, lightheadedness, asphyxiation, and fainting.
Some gases are stored in metal cylinders under high pressure. Compressed gas cylinders can explode causing injury from
high speed projectiles.
Lasers
Light of a single color emitted in a narrow beam. Hazards from lasers are classified as

Class 1 – No hazard

Class 2 – Insufficient power to cause eye damage within the normal aversion response time. (Class 2a is a Specialcase Class 2 laser designed to be inaccessible to viewing.)

Class 3a – Direct viewing of the beam can cause eye injury

Class 3b – Direct and indirect viewing of the beam can cause eye injury

Class 4 – Direct and indirect viewing of the beam can cause eye injury. Also, a potential fire hazard.
Microbiological
Living organisms such as viruses, bacteria, fungi, prions, and parasites. Those that are capable of causing disease are
Agents
called pathogens. The effects of these agents are organism dependent and can range from mild, treatable to severe,
untreatable. Hazards from microbiological agents are classified as

Biological Safety Level 1 – no hazard to healthy adults

Biological Safety Level 2 – cause mild to severe illness

Biological Safety Level 3 – cause severe illness and possible death (Minors are not allowed)

Biological Safety Level 4 – Not allowed at GRU
Radiation/Radioact High energy particles (alpha & beta) or waves (X-rays). Unprotected exposure can cause skin or eye damage, cellular
ive Materials
damage, and long-term health problems.
Recombinant
DNA that has been genetically engineered (altered) by combining it with DNA from another source. Viruses may be used as
Materials
vectors to infect (transfect) cells with the foreign DNA.
A transgenic organism is one that has had genes from another organism inserted into its genes. The consequences of
introducing such foreign genes into a human body may be difficult to predict.
Toxins
Poisons produced by microbiological organisms, plants, or animals. These agents can cause tissue and organ damage or
death.
*This table to be used as a reference for the Consent Form.
Examples
Scratch, bite (physical injury)
Rabies, toxoplasmosis (zoonotic
disease)
Benzene (carcinogen)
Thalidomide (teratogen)
Acetone, xylene, alcohol
(flammables)
Peroxides, acrylamide (reactives)
Acids, bases (corrosives)
Cyanide (toxin)
Autoclaves/sterilizers (burns)
Nitrogen, helium, any other nonoxygen gas (asphyxiant)
Hydrogen (flammable)
Ammonia (toxic)
Nitrogen lasers (Class3b)
Examples of Class 4 lasers: Free
Electron Laser: Argon ion laser,
Ti-Sapphire laser, and diode
laser
Baker’s Yeast, E.coli K12
(Level 1)
Influenza, Salmonella (Level 2)
Tuberculosis, AIDS (Level 3)
Uranium, Phosphorus 32,
Sodium 35, X-rays
Adenovirus, adeno-associated
virus (viral vector)
Ricin (plant)
Snake venom (animal)