AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR 2011 Cardinal Kids Camp

I/We, the undersigned, parent(s)/guardian(s) of ______a minor, do hereby authorize, Stanford University Staff, as agents for the undersigned, to consent to an X-ray, examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of, any physician and/or surgeon licensed in any of the United States, or, if in a foreign country and no physician licensed to practice in any of the United States is reasonably available, by a duly licensed physician deemed competent to render the necessary.

It is understood that this authorization is given in advance of any specific diagnosis treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforesaid physician in the exercise of his or her best judgment may deem advisable.

I understand that as a parent/legal guardian, I will be responsible for the cost of any service or treatment provided by Stanford.

This authorization shall be valid and effective from ______, 2011 until ______, 2011 unless revoked sooner in writing delivered to Stanford.

I understand that in order to provide timely and effective medical attention to a minor Stanford has requested the completion of the attached Voluntary Heath History Information.

I understand that this form is voluntary and I ( ) elect to, ( ) elect not to complete this form.

Signature:

Name Printed (Parent/Guardian):

Please submit all forms by email or fax to: Sarah Roe Reunion Homecoming Registration Assistant

Email: [email protected] Fax: (650) 724‐1552

Questions? (650) 723-2006

AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR 2011 Cardinal Kids Camp

VOLUNTARY HEALTH HISTORY INFORMATION This information is confidential and will be used only in case of emergency. Childs First Name Last Name Sex: M / F Date of Birth

Does your child have or has Is your Child Subject to: Yes or No ever had: Yes or No Colds Heart Trouble Sore throat Sinus Trouble Fainting spells Hernia Bronchitis Appendicitis Convulsions Has appendix been removed? Cramps Allergies Date of child’s last tetanus vaccination: Please identify child’s allergies, including allergies to food, medications, or drug reactions you know about:

Is your child currently under any type of medical treatment? If yes, please describe: Is your child currently taken any prescription medication? If yes, please identify name of medication, dosage, times taken:

Please identify over-the-counter medications that we may administer. For example: Antacid, Aspirin.

Please list any disabilities or disorders that may affect your child’s participation, such as eyesight, hearing, speech, paralysis, diabetes, ulcer, etc.

Is there any history of behavior disorders or emotional disturbances, such as difficulties in relationships with authority figures or peers, or abnormally severe moodiness?

Has your child been under psychiatric treatment within the past three years?

Name, address and telephone number of child’s physician

Remarks and any special instructions:

RELEASE OF LIABILITY, ASSUMPTION OF RISK, AGREEMENT TO INDEMNIFY AND NOT TO SUE FOR MINORS PARTICIPATING IN THE 2011 REUNION HOMECOMING KIDS CAMPS

I hereby give my consent for the below named minor to Individually, and as parent or legal guardian of the minor, I participate in the 2011 Reunion Homecoming Cardinal Kids agree that this release of liability, assumption of risk, agreement Camp scheduled during October 20- October 22, 2011. to indemnify and not to sue is to be as broad and inclusive as is permitted by the laws of the State of California and that if any I understand that the minor’s participation in the 2011 Reunion portion of it is held invalid it is agreed that the balance shall Homecoming Cardinal Kids Camp involves potential risks of continue in full force and effect. injury, both serious and minor, including but not limited to head or other injuries, loss of sight, broken bones, brain damage, I understand that by signing this release of liability, assumption paralysis and death. of risk, agreement to indemnify and not to sue, is legally binding on me, the minor, our heirs, personal representatives, relatives Individually, and as parent or legal guardian of the minor, I and assigns and that I am giving up both my and the minor’s hereby certify that I know the minor’s state of health and well- legal rights and remedies which otherwise would be available to being and that the minor is physically fit to participate in the me and/or the minor, our heirs, personal representatives, 2011 Reunion Homecoming Cardinal Kids Camp. relatives or assigns against The Leland Stanford Junior University, its Board of Trustees, officers, agents, employees, Individually, and as parent or legal guardian of the minor, I servants, students and volunteers. expressly assume any and all risks of injury and/or death associated with, arising out of or related to the minor’s I have carefully read this release of liability, assumption of risk, participation in the 2011 Reunion Homecoming Cardinal Kids agreement to indemnify and not to sue and fully understand it. I Camp at Stanford University. have explained the significance of this release of liability, assumption of risk, agreement to indemnify and not to sue to the Recognizing and understanding the potential risks of injury, I, minor. individually, and as parent or legal guardian of the minor, agree not to sue and to defend and indemnify The Leland Stanford I am of legal age and voluntarily sign this release of liability, Junior University, its Board of Trustees, officers, agents, assumption of risk, agreement to indemnify and not to sue. employees, servants, students and volunteers for any loss, damage or injury associated with, arising out of or related to the Please initial to indicate whether you are the parent or legal minor’s participation in the 2011 Reunion Homecoming Cardinal guardian of the minor. Kids Camp regardless of cause, including negligence. Minors name (printed) Individually, and as parent or legal guardian of the minor, I hereby release and discharge The Leland Stanford Junior University, its Board of Trustees, officers, agents, employees, Print Name of Parent or Legal Guardian servants, students and volunteers, who through negligence or carelessness, might otherwise be liable to me, the minor, our Relationship to minor heirs, personal representatives, relatives or assigns from all liability associated with, arising out of, or related to the minor’s Street Address participation in the 2011 Reunion Homecoming Cardinal Kids Camp including all liabilities associated with and any and all claims that may be filed on behalf of or for the named minor. City, State, Zip

Cell phone

Please submit all forms by email or fax to: Signature Sarah Roe

Reunion Homecoming Registration Assistant Date

Email: [email protected] Fax: (650) 724‐1552

Questions? (650) 723-2006