Renee Block, ARM

RISK MANAGER

Release and Hold Harmless Agreement

I release and hold harmless Rice University, including, but not limited to, its trustees, officers, employees, representatives, agents and affiliates, from any and all liabilities, personal injuries, and damages to or loss of personal property arising, directly or indirectly, in connection with my child's use of the facilities and equipment of Rice University.

I certify that my child has medical/hospitalization insurance with _________________ company, policy number ___________________. I understand that should my child require medical treatment, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I consent to such treatment for my child as may be deemed necessary under the circumstances, including, but not limited to, x-ray examinations, surgery and anesthesia. Any expense not covered by insurance shall be my sole responsibility.

By signing below I certify that I understand and agree to abide by the release of liability and medical authority as set forth above.

Parent's Signature: _________________________________

Date: __________________________________

Last modified January 5 th, 2001