UT Houston Medical School’s Pre-JAMP Symposium April 19th, 2013
Registration Form
Spots are limited and are on a first come first serve basis
Please Note: Registration is not complete until you receive a confirmation e-mail
*High School upperclassmen and college freshmen only*
Please return to MS.AdmissionsOutreach@UTH.TMC.edu by April 8th
You will need to fill out both forms--Registration and the appropriate waiver (Adult for those 18 and
older). Please also plan to wear close toed shoes and long pants.
Name: ________________________________________
Date: ______________________________
School: _______________________________________
Grade/Classification: _________________
E-mail Address: _________________________________________________________
Have you attended a JAMP Symposium before?
Are you 18 or older?
Yes
No
When & Where: _____________________
Yes
No
If not, please make sure to fill out the Risk Waiver form for Minors.
Do you have any food allergies?
Yes
No
If so, please list: _________________________________
How did you hear about the Symposium? _____________________________________________________
Please fill out both forms and return to MS.AdmissionsOutreach@uth.tmc.edu or
Fax: (713) 500-0616 Attn: Rae Magel
ASSUMPTION OF RISK AND WAIVER OF CLAIMS FOR MINORS
PARTICIPANT: (Name and Address)
INSTITUTION:
__________________________________
__________________________________
The University of Texas Health Science Center at HoustonMedical School
__________________________________
DESCRIPTION OF ACTIVITY OR TRIP: _Pre-JAMP Symposium at UT Houston Medical School______
Activities in the SCSC and Gross Anatomy Lab, Medical School Campus and Memorial Hermann Hospital Tour__
LOCATION: __Medical School Building, SCSC, Gross Anatomy Lab, UTH Campus, Memorial Hermann Hospital__
DATE(s): ____4/19/2013_________
I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and am fully competent to sign this
Agreement.
I give permission for Participant to participate in the above-referenced Activity or Trip. I acknowledge that the nature of the
Activity or Trip may expose Participant to hazards or risks that may result in Participant's illness, personal injury or death and I
understand and appreciate the nature of such hazards and risks.
In consideration of Participant being permitted to participate in the Activity or Trip, I hereby accept all risk to Participant's
health and of his/her injury or death that may result from such participation and I hereby release the above named Institution, its
governing board, officers, employees and representatives from any and all liability to Participant, Participant's personal
representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to
Participant's property and for any and all illness or injury to Participant's person, including his/her death, that may result from or
occur during Participant's participation in the Activity or Trip, whether caused by negligence of the Institution, its governing
board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the Institution and its
governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to
property that may result from Participant's negligent or intentional act or omission while participating in the described Activity
or Trip.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE AN ASSUPMTION OF RISK
AND WAIVER OF ALL CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT'S INJURY OR DEATH OR
DAMAGE TO PARTICIPANT'S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED
ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY
FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT'S
NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
__________________________________
__________________________________
Signature of Parent/Guardian
Signature of Witness
__________________________________
__________________________________
Address (if different than Participant's)
Date Signed
ASSUMPTION OF RISK AND WAIVER OF CLAIMS FOR
ADULT STUDENTS
STUDENT: (Name and Address)
INSTITUTION:
__________________________________
__________________________________
The University of Texas Health Science Center at HoustonMedical School
__________________________________
DESCRIPTION OF ACTIVITY OR TRIP: Pre-JAMP Symposium at UT Houston Medical School_______
Activities in the SCSC and Gross Anatomy Lab, Medical School Campus and Memorial Hermann Hospital Tour__
LOCATION: Medical School Building, SCSC, Gross Anatomy Lab, UTH Campus, Memorial Hermann Hospital
DATE(s):____ 4/19/2013_________
I, the above named student, am eighteen years of age or older and have voluntarily applied to participate in the above Activity or
Trip. I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks that may result in my illness,
personal injury or death and I understand and appreciate the nature of such hazards and risks.
In consideration of my participation in the Activity or Trip, I hereby accept all risk to my health and of my injury or death that
may result from such participation and I hereby release the above named Institution, its governing board, officers, employees
and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all
claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my
death, that may result from or occur during my participation in the Activity or Trip, whether caused by negligence of the
Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold
harmless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of
any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the
described Activity or Trip.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE AN ASSUMPTION OF RISK
AND WAIVER OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY
PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP AND IT
OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF
ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR
OMISSION.
__________________________________
__________________________________
Signature of Participant
Date
__________________________________
__________________________________
Witness
Date