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Vanderbilt University Participation Agreement for Minors Under 18 Years of Age

Name of Participating Minor and Activity

I, (Print Name of Minor’s Parent or Legal Guardian)_________________________________ state that (Print Minor’s

Legal Name) ___________________________________ (hereafter referred to as “the minor”) hereby consent to his/

her attendance and participation in the Vanderbilt Observational Experience program, at Vanderbilt University Medi-

cal Center, occurring on/between ____________________________ and __________________________ (insert

observation dates).
Permission to Participate and General Release
In exchange for allowing the minor to participate in this event or program, the minor by and through the under-
signed, agrees to release from liability, indemnify, and hold harmless the Vanderbilt University Medical Center, its
trustees, employees, agents, volunteers, and/or assigns from any and all claims, demands, losses, expenses, actions
or causes of action to the minor’s person or damage to the minor’s property which arises out of or occurs during or as
a consequence of the minor’s participation in the event or program, whether or not such injury or damage may have
been caused, in whole or in part, by any negligence or want or care on the part of the Vanderbilt University Medical
Center, its trustees, employees, agents, volunteers, and/or assigns.
Emergency Treatment Authorization
I authorize the Vanderbilt University Medical Center to provide routine first aid in case of illness or injury. If a parent
or guardian cannot be reached, I give my permission for Vanderbilt University Medical Center to authorize emergency
treatment for my child at Vanderbilt University Medical Center, or transported to another appropriate health care
facility that I request _______________________ (insert name of facility). I acknowledge that any medical treatment
will be my financial responsibility and not that of Vanderbilt University Medical Center.
Emergency Contact
Emergency Contact Name: Relationship:

Emergency Contact Phone (1) Phone (2)

Photo/Image Release
I grant permission for photos/images of the minor to be used by Vanderbilt University Medical Center in any Vander-
bilt University Medical Center publications and any other way the Medical Center deems necessary and appropriate
to promote its activities and mission.
Acknowledgement
I, the undersigned, state that I am the parent/legal guardian of the minor whose name appears above. I understand
that the above terms and conditions apply to said minor and to myself. I further understand that that said minor can-
not participate under ANY circumstances in the above specified event or program without parental consent and that
the minor will not be allowed to participate without entering into this agreement. This document is binding upon my-
self, the said minor, and any person suing on behalf of said minor.
Parent’s/Guardian’s Printed Name and Signature (if under 18)

PRINT SIGN DATE
Vanderbilt Protection of Minors Provision: Vanderbilt University Medical Center personnel adhere to Tennessee
state law on mandatory child abuse. In addition to external reporting, Vanderbilt has a mandatory internal child
abuse reporting procedure. If you have reason to believe abuse or inappropriate behavior has occurred concerning a
minor participating in a Vanderbilt University program, please consult the program director, or Risk Management
(615-936-0660), or report via the Vanderbilt hotline at 866-783-2287. The Tennessee Child Abuse reporting hotline
number is 877-237-0004.