Emergency Medical Release
Imagine Tomorrow – Adult Participant
In an emergency requiring medical attention or a situation reasonably believed by Washington State
University (WSU) authorized agents including Imagine Tomorrow staff to be an emergency, I authorize
WSU and its authorized agents to obtain emergency medical care for me. I will be responsible for
any expenses incurred in so doing, including but not limited to care by health care professionals,
hospital care, and ambulance or other services. In addition, the health care provider has permission
to obtain a copy of my health record from providers who treat me and these providers may talk with
the program’s staff about my health status.
I hold harmless and agree to indemnify Washington State University, its authorized agents, and
employees and the staff of Imagine Tomorrow from decisions to seek emergency treatment.
________________________________________________________________
Please complete the following:
Imagine Tomorrow Adult Participant: _______________________________ Date of Birth: ______________________________
School Name and State: ___________________________________Advisor Name: ____________________________________
First
Last
Address: ___________________________________________________________________
City: ______________________________ State: ______________ Zip: ___________
Phone: (____) _________________________ E-mail: ___________________________
Health-Care Providers:
Name of participant’s primary doctor(s): _______________________________ Phone: (_____) _____________
Name of dentist(s):________________________________________________ Phone: (_____) ______________
Name of orthodontist(s):____________________________________________ Phone: (__ __) ______________
Additional health care provider(s) name(s) and contact numbers:
_____________________________________________________________________________
_____________________________________________________________________________
Medical Insurance Information:
This participant is covered by family medical and/or hospital insurance
Yes
No
Primary Insurance Company __________________________________ Policy Number ___________________
Subscriber __________________________ Insurance Company Phone Number (_____) ___________________
Secondary Insurance Company ________________________________ Policy Number ____________________
Subscriber _________________________
Insurance Company Phone Number (_____) ____________________
Name of a person to contact in case of emergency:
_____________________________________________________________________________
Phone: (____) _____________________ E-mail: ______________________________
Relationship to participant: _______________________________________________
________________________________________________________________
I voluntarily sign this authorization. I have read it, and I understand its content and significance.
________________________________________
______________
________________________________________
______________
Witness Signature
Date
Signature of Imagine Tomorrow Adult Participant
Date
Mail this completed form to the
address below by April 1, 2015.
Imagine Tomorrow
Washington State University
PO Box 645222
Pullman, WA 99164-5222
IMAGINE TOMORROW ACTIVITIES
For Participants Age 18 or Older
May 29–31, 2015
ASSUMPTION OF RISK
I understand that there are risks in participating in recreational activities and educational workshops at
the Imagine Tomorrow activities at Washington State University (WSU).
In consideration for and as a condition of being allowed to participate in this voluntary activity, I
agree to take full responsibility for all risks that exist, including the risk of death, personal injury,
or property loss or damage. I understand that there may also be risks that WSU cannot predict or
foresee, and I also assume full responsibility for those risks.
Risks in participating in the Imagine Tomorrow activities (including touring campus facilities and
participating in activities in the Recreation Center), include, but are not limited to: temporary
or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage
damage, orthopedic damage, head, neck or spinal injuries, loss or use of arms and/or legs, eye
damage, disfigurement, burns, drowning or death. I also recognize that there are both foreseeable and
unforeseeable risks of injury or death that may occur as a result of traveling to or from the Imagine
Tomorrow activities that cannot be specifically listed. Further, I recognize that the actions of other
participants in the activity may cause harm or loss to my person or property.
RELEASE OF LIABILITY
I release the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers,
employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses, which I
may sustain, as a result of or related to participation in the above event. My participation includes, but
is not limited to, travel to and from the event in a private or public vehicle, any activity connected with
the event itself, and use of state equipment or facilities for the event whether on or off WSU property.
I have carefully read this document, understand its contents and am fully informed about this
program and circumstances. I am aware that this document is a contract with WSU and the
program sponsors. I sign it freely and voluntarily.
DATED THIS _____ DAY of _______, 20____.
_________________________________
Name (Printed)
_______________________________
Signature
_________________________________
Witness’s Name (Printed)
________________________________
Witness’s Signature
_________________________________
School Name and State
________________________________
Advisor Name
Mail this completed form to the
address below by April 1, 2015.
Imagine Tomorrow
Washington State University
PO Box 645222
Pullman, WA 99164-5222
Image and Voice Recording Consent
Imagine Tomorrow - Adult Participant
_________________________________________________ (print name), hereby grant permission to Washington State University (WSU) to
be photographed or otherwise have images or voice recordings made (including but not limited to digital photographs, video or digital
moving images and/or voice recordings), for WSU publication or promotional purposes in any medium (including but not limited to
print media, newspaper, television, video, motion picture, or Web site on the Internet).
I additionally consent to the use of my name and/or interview comments in connection with WSU publication or promotional purposes
in print media, newspaper, television, video, motion picture, or Web site on the Internet.
I understand that consent to use my likeness or voice recordings is not a condition of participating in the activity and that consent can
be refused without any impact in the ability to fully participate in the program.
No inducements or promises beyond our acceptance of an opportunity to promote WSU and its programs have been given to the
persons signing below.
Any other use of images and/or recordings, my name, and/or interview comments requires advance permission.
I understand that I can revoke this consent at any time upon notice to WSU, at which time either or both of us will sign a copy of the
denial (below) for use of images or voice recordings.
I agree to use of digital images or voice recordings as set forth above:
________________________________________________
__________________
Signature of Adult Participant
Date
________________________________________________
__________________
_____________________
Signature of Witness (required)
Date
I do not agree to use of digital images or voice recordings as set forth above:
________________________________________________
__________________
________________________________________________
__________________
Signature of Adult Participant
Signature of Witness (required)
_______________________
_______________________
School Name and State
______________________
________________________
________________________
Advisor Name (First, Last)
Date
Date
Mail this completed form to the
address below by April 1, 2015.
Imagine Tomorrow
Washington State University
PO Box 645222
Pullman, WA 99164-5222