Boston College Experience Participation Agreement
I. General Information Concerning Child
Name of Student: _________________________________________ Date of Birth: ____/____/_____
(Print Last, First, Middle)
(MM/DD/YYYY)
II. Parent or Guardian Information:
Name of Responsible Parent/Guardian: _____________________________________________________
Does this person speak English?
Yes
No
If no, please list preferred languages
____________________________________________________
Home Address: ________________________________________________________________________
_____________________________________________________________________________________
Home Phone: (_____) ____ - ________ Business Phone: (_____) ____ - ________
Mobile Phone: (____) ____ - ________
III. Emergency Contact Information:
Name of Emergency Contact:
_____________________________________________________________
Does this person speak English?
Yes
No
If no, please list preferred languages
____________________________________________________
Relation to Student:
_____________________________________________________________________________________
Home Address: ________________________________________________________________________
_____________________________________________________________________________________
Work address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Home Phone: (_____) ____ - ________ Business Phone: (_____) ____ - ________
Mobile Phone: (____) ____ - ________
IV. Health Insurance Information:
Health Insurance Company: ______________________________________________________________
Policy Identification Number: ____________________________________________________________
PLEASE ATTACH PHOTOCOPY OF INSURANCE CARD (BOTH SIDES)
V. Health Information
A. Allergies. Is your child allergic to any of the following?
Medications: Yes/No (circle): If yes please explain: ___________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Food: Yes/No (circle): If yes please explain: _________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Insect Bites: Yes/No (circle): If yes please explain: ___________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
B. Medications:
Please List all medications your child is currently taking, including epi-pen, inhaler or insulin injection
(add separate sheet if needed):
Medication Dose Frequency Reason
1._______________________ ______________ _______________________ ____________________
2._______________________ ______________ _______________________ ____________________
3._______________________ ______________ _______________________ ____________________
PLEASE NOTE: The Program staff prefers whenever possible that medication be administered outside of
Program hours, under the supervision of a parent or guardian. If medications need to be administered
during program hours, please sign the appropriate authorization below:
□ I hereby authorize Program staff to administer to my child the following medication(s):
____________________________________________________________________________.
I understand that medications must be delivered to the program staff in original containers bearing the
name of my child, the prescribing doctor, directions for use, and showing the number of tablets or
capsules, as appropriate. No medication will be accepted in bags separate from the original container. I
acknowledge that the medication will be administered by a supervisor who is not a licensed health care
professional.
Name of Parent or Guardian: ________________________________________
(Print Last, First, Middle)
Signature: ____________________________
Date: _________________________________
□ I hereby authorize my child to self-administer his or her epi-pen, inhaler, or insulin when he or she
requires it during program hours.
Name of Parent or Guardian: ________________________________________
(Print Last, First, Middle)
Signature: ______________________________
Date: ___________________________________
C. History:
Please attach a list of all significant past or current medical surgical or mental health conditions, including
hospitalizations.
VI. Student Participation Agreement
The Boston College Experience has been modeled off of the lived experiences of Boston College
undergraduate students. We have taken great care to provide a variety of opportunities for students to
engage in the Boston College and greater Boston communities. Some components of the program are
required as outlined by our Community Expectations since we have invested a significant amount of time
and money to plan these activities. Several components of the program are optional to provide the
opportunity for students to plan their own schedule and ensure time for completing coursework. Program
participants are expected to attend all required activities as requested by program staff members as well as
to abide by all university and program policies as outlined by the university Student Guide
(www.bc.edu/studentguide) and the BCE Community Expectations ( www.bc.edu/bce ). Failure to attend
required programs without express written permission, missing class, or violation of university and/or
program policies may result in dismissal from the program without refund. I also understand that pictures
or video may be taken at program activities and hereby consent and release Boston College from any
liability or claim whatsoever, now and hereafter arising, with respect to the use of photographs of the
undersigned in any Boston College publication and publicity materials, including the internet.
Signing this form indicates that program participants and parents/guardians have read and agree to the
terms of this agreement for participation in the Boston College Experience.
Student Name:
_____________________________________
Student Signature:
_____________________________________
VII. Parental Consent and Release
I understand that participation by my child in the Boston College program named above involves a certain
degree of risk. I also understand that participation in the Program is entirely voluntary and requires
participants to abide by applicable rules and standards of conduct. Violation of university and/or program
policies may result in dismissal from the program without refund.
In case of an emergency involving my child, I understand that effort will be made to contact me or the
individual listed as the emergency contact person.
In the event that neither me nor the emergency contact person can be reached, permission is hereby given
to the medical provider selected by those in charge of the Program to secure proper treatment, including
hospitalization, anesthesia, surgery, or injections of medication for my child.
Medical providers are authorized to disclose protected health information to the supervisors of the
Program, and/or any physician or health care provider involved in providing medical care to my child,
including examination findings, test results, and treatment provided for purposes of medical evaluation of
the participant, follow-up and communication with the me, and/or determination of my child’s ability to
continue in the Program activities.
I have carefully considered the risk involved and give consent for my child to participate in these
activities. I approve the sharing of the information on this form with program administrators and
professionals who need to know of medical situations that might require special consideration for the
safety of my child.
I also understand that pictures or video may be taken at program activities and hereby consent and release
Boston College from any liability or claim whatsoever, now and hereafter arising, with respect to the use
of photographs of my child in any Boston College publication and publicity materials, including the
internet.
I release the Boston College, its employees and volunteers, including, without limitation, those persons
having responsibility for the Program from any and all claims or liability arising out of this participation.
Signature of Parent or Guardian: ____________________________________________
Name of Parent or Guardian: _______________________________________________
Boston College Athletic Association
Waiver of Liability
Boston College Summer Session
__________________________________
Organization/Name of Responsible Person
140 Commonwealth Ave.
__________________________________________________
Address
617-552-3800
__________________________________________________
Phone Number
BCE - Access to exercise facilities
__________________________________________________
Activity
__________________________________________________
Signature of Applicant
__________________________________________________
Date
For BCE Staff Use Only
General Insurance Release
In consideration of the use of Boston College Athletic Facilities (“User”) understands that User assumes the risk of using these
facilities and shall indemnify Boston College for all damages caused by User, its representatives, employees, agents, and assignees.
Any personal property that User brings to Boston College is a User’s sole risk and is not the responsibility of Boston College. User
releases Boston College from any liability for loss, damage, or theft of such property.
Further, User shall reimburse Boston College for any loss, expense, repairs, or damages to Boston College property resulting from the
use of said property.
User agrees to indemnify, defend, and hold harmless Boston College, its trustees, officers, employees, and students, from any and all
claims, suits, actions, and liability including legal and defense cost arising, or alleged to arise, out of injuries or damages sustained by
any persons, person, or property (including without limitation claims based on alleged defamation or on infringement of rights to
copyright, trademark, or other intellectual property) on account of, or in consequence of any act or omission, neglect or misconduct, or
in violation of any law, ordinance, or regulation, by the undersigned, its representatives, employees, agents, and assignees, which was
caused to occur during user’s use of Boston College facilities.
Print Name of Student
Student Signature
Parent/Guardian
Parent/Guardian Signature
_________________
_________________________________
__________________
____________________________